Disorders of the Stomach

Question 1

What is peptic ulcer disease?

Answer 1

It is a break in lining of either the stomach (gastric ulcer), sm. intestine (duodenal ulcer-MOST COMMON), or lower esophagus.

Question 2

What are the causes/risk factors for peptic ulcers?

Answer 2

o H. pylori bacteria infection
o Hypersecretion of stomach acid and pepsin
o Use of NSAIDs (ibuprofen, advil, motrin)– older adults are more susceptible
o Acid production by cigarette smoking
o Stress d/t illness
o Crohn’s disease
o Liver cirrhosis
o Other conditions with similar symptoms: Gastritis, inflammation of gallbladder, stomach cancer, coronary heart disease

Question 3

Clinical manifestations of peptic ulcer disease

Answer 3

o Most Common symptom: Waking at night with upper abdominal pain, upper abdominal pain that improves with eating**
• Burning or dull ache
o Belching
o Vomiting
o Wt loss
o Poor appetite
o 1/3 older adults - asymptomatic (bleeding may be first sign)
o Chronic intermittent pain in the epigastric area 2-3 hours after eating.
o Relieved by food or antacids

Question 4

What are acute complications of peptic ulcer disease?

Answer 4

o Hematemesis: vomiting of blood; commonly assoc w/ UPPER GI bleed
o Melena: black tarry stool caused by GI tract bleed (Hemoglobin in blood being altered by digestive chemicals + intestinal bacteria)
o Hematochezia: passage of fresh blood through the anus; commonly assoc w/ lower GI bleed

Question 5

Melena

Answer 5

lack tarry stool caused by GI tract bleed (Hemoglobin in blood being altered by digestive chemicals + intestinal bacteria)

Question 6

Hematochezia

Answer 6

passage of fresh blood through the anus; commonly assoc w/ lower GI bleed

Question 7

Hematemesis

Answer 7

vomiting of blood; commonly assoc w/ UPPER GI bleed

Question 8

What are the chronic manifestations of peptic ulcer disease?

Answer 8

Occult bleeding (in stool)

Question 9

What is the most characteristic sign of a gastric ulcer?

Answer 9

Pain when eating, pain relieved hours after (there’s more acid produced in stomach, irritates lining)

Question 10

What is the most characteristic sign of a sm. intestine ulcer?

Answer 10

Pain is RELIEVED when eating, pain hours after

Question 11

What are potential complications of PUD?

Answer 11

o Bleeding (15% of cases), perforation, obstruction of the duodenum

Question 12

Diagnosis and treatment:

Answer 12

presenting symptoms and confirmed by tests:
o Barium swallow
o Endoscopy
o H. Pylori test (test blood for antibodies)
o Urea breath test
o Testing stool for bacteria
o Biopsy of stomach to detect H. Pylori
• Goals of management:
o Relieve the causes and effects of hyperacidity
o Administering antacids and PPIs (proton pump inhibitors)
o Treat H. Pylori w/ antibiotics

Question 13

Define a gastrointestinal bleed and provide the cause(s)

Answer 13

All forms of blood loss from the gastrointestinal tract, from the mouth to the rectum.

o Upper gastrointestinal bleeding causes include: peptic ulcer disease, esophageal varices (extremely dilated sub-mucosal veins in the lower third of the esophagus) due to liver cirrhosis, and cancer

o Lower gastrointestinal bleeding causes include: hemorrhoids, cancer, and inflammatory bowel disease

Question 14

Clinical manifestations of a GI bleed

Answer 14

• Vomiting red blood, vomiting black blood, bloody stool, or black stool.
• With small amts of bleeding there’s sometimes no symptoms. If small amt of bleeding continues long term, leads to Iron deficiency anemia resulting in fatigue or chest pain.
• Abdominal pain, pale skin, or syncope (d/t low blood volume + anemia)

Question 15

Diagnostic tests for a GI bleed

Answer 15

• Medical history + Physical Examination
• Blood test: CBC (check Hmg + hematocrit)

Stool Analysis*
•	Elimination patterns and characteristics:
•	Color
•	Consistency
•	Volume
•	Shape
•	Odor

• Endoscopy: upper + lower GI tract to locate bleeding

Fecal Occult Blood Test (FOBT):
• Shows small amounts of blood loss from GI tract
• Small amount of stool placed on test strip, apply solution
• Blue= blood present
• Can be caused by many diseases:
• Cancer
• Stomach or Intestinal Ulcer
• Diverticulitis (inflammation of a diverticulum (small pouches), especially in the colon, causing pain and disturbance of bowel function.)

Question 16

Treatment of a GI bleed

Answer 16

• Initial treatment focuses on resuscitation:
o Intravenous fluids
o Blood transfusions (Not recommended unless Hmg

Question 17

What are “inflammatory Bowel diseases (IBD)”?

Answer 17

Group of inflammatory AUTOIMMUNE conditions related to colon and small intestine. The immune system is attacking elements of the digestive system.

o Crohn’s disease and ulcerative colitis are the 2 principle types of IBD

-It has periods of remissions and exacerbations

Question 18

What is ulcerative colitis

Answer 18

It is a type of CHRONIC inflammatory bowel disease that causes ulcerations in the colonic mucosa in the sigmoid colon and rectum.

It is an AUTOIMMUNE disease where the T-cells infiltrate the colon leading to ulcers.

Has periods of remissions and exacerbations

Question 19

What is the cause of ulcerative colitis?

Answer 19

No definitive known cause; but suggested causes (genetics and stress) are:
o Infectious, immunologic (anticolon antibodies), dietary, genetic (supported by family studies and identical twin studies)

Question 20

What are the clinical manifestations of ulcerative colitis?

Answer 20

Symptoms:

o Constant diarrhea (10-20/day) mixed with bloody, bloody stools, cramping

Question 21

What is the treatment for ulcerative colitis?

Answer 21

o Broad-spectrum antibiotics and steroids
o Immunosuppressive agents
o Surgery

Goal of Treatment: induce remission w/ medication, followed by maintenance meds to prevent relapse

Question 22

What are potential long term complications of ulcerative colitis?

Answer 22

o An increased colon cancer risk has been found in patients with ulcerative colitis.
o Anemia

Question 23

What is Crohn’s Disease (aka “granulomatous colitis”, “ileocolitis” or “regional enteritis”)

Answer 23

• Idiopathic inflammatory disorder; affects both large and small intestines, can also affect mouth, stomach, esophagus, anus
• Transmural pattern of inflammation: inflammation span entire depth of intestinal wall
o Biopsy show mucosal inflammation (characterized by focal infiltration of neutrophils into epithelium), chronic mucosal damage (aeb blunting of intestinal villi)

-has periods of remissions and exacerbations

Question 24

What are the main differences btwn ulcerative colitis and crohn’s disease

Answer 24

Crohn’s disease has skip lesions and can occur anywhere in GI tract. There are also “transmural lesions” affecting the FULL THICKNESS of bowel wall.

UC does NOT have skip lesions and ONLY OCCURS in colon and rectum. UC is restricted to only affecting the mucosa (epithelial lining)

Question 25

What are the clinical manifestations of crohn’s disease

Answer 25

o Abdominal pain
o Diarrhea (bloody, if severe inflammation)
o Fever
o Wt loss
• Anemia may result due to malabsorption of vitamin B12 and folic acid

Question 26

Treatment of crohn’s disease

Answer 26

• No cure: Periods of exacerbations and remissions
o Remission: medication, lifestyle + dietary changes (eat smaller amts more often), reduce stress, moderate activity + exercise
o Surgery: usually CONTRAINDICATED and does not show to prevent remission
o Adequate control to improve quality of life
o Tx: active symptoms, treat acute problem
• Treatment is similar to ulcerative colitis

Question 27

What are possible long term complications of crohn’s disease?

Answer 27

Complications (in GI tract)
o	Formulation of a fistula (a conduit) between different areas of the GI tract or between the GI tract and the bladder, vagina, urethra, or skin.
o	Intestinal Obstruction
o	Abcess Formation
o	Bowel obstruction

Those with this disease are at greater risk for bowel cancer

Other long term complications OUTSIDE of the GI tract:
o Anemia
o Skin rashes: d/t infections
• Pyoderma gangrenosum: condition that causes tissue to become necrotic, causing deep ulcers that usually occur on legs
• Erythema Nodosum: inflammatory condition characterized by inflammation of fat cells under skin, resulting in tender red nodules or lumps that are usually seen on both shins
o Arthritis
o Inflammation of eye
o Fatigue

Question 28

What is Pyoderma gangrenosum

Answer 28

A condition that causes tissue to become necrotic, causing deep ulcers that usually occur on legs. This is a potential long term complication from CROHN’S

Question 29

What is Erythema Nodosum

Answer 29

An inflammatory condition characterized by inflammation of fat cells under skin, resulting in tender red nodules or lumps that are usually seen on both shins. This is a potential long term complication from CROHN’S

Question 30

What is “intussusception”

Answer 30

when part of the intestine folds into another section of intestinal wall (can cause intestinal obstruction)

Question 31

What is intestinal obstruction

Answer 31

Mechanical or functional obstruction preventing normal transit of products of digestion

Question 32

What causes intestinal obstruction

Answer 32

Multiple Causes:
o	Tumor
o	Fecal impaction
o	Intersusception: part of intestine folds into another section of intestinal wall
o	Simple
o	Functional

Question 33

What are the clinical manifestations of intestinal obstruction

Answer 33

o	Abdominal pain
o	Swollen/ distended abdomen
o	Nausea/vomiting
o	Constipation
•	Can manifest with: Pain, Constipation, “Gassyness”, Fullness, Diarrhea, n/v

Intestinal Obstruction can lead to:
o Water and electrolyte imbalance (d/t vomiting)
o Respiratory complications (pressure d/t distended abdomen or aspiration of vomit)
o Perforation (big concern!) from prolonged distention or bowel ischemia d/t prolonged distention, pressure from foreign body
o Sepsis

•	Small bowel obstruction: 
o	Pain is cramping and intermittent
o	Spasms last a few minutes
o	Pain is central, mid-abdominal
o	Vomiting occurs before constipation

• Large Bowel Obstruction:
o Pain is lower in abdomen
o Spasms last longer
o Constipation occurs earlier, vomiting less prominent

• Proximal obstruction of large bowel may present as small bowel obstruction

Question 34

Treatment for intestinal obstruction?

Answer 34

• Treatment: surgery + treatment of causative agent
o Some may resolve spontaneously
o Decompression of abdomen with NGT (Nasogastric Tube)
o Correction of dehydration and electrolyte abnormalities is important
o Opioid pain relievers may be used for patients with severe pain
o Anti-emetics may be administered if the patient is vomiting and has severe nausea
o Surgery

Question 35

What is “diverticular disease”

Answer 35

Altered structure and function of the large intestine walls with diverticulum (diverticulum=small sac, outpouching along the wall of colon), causing weakness
• Weakness leads to “outpouching”

Gastrointestinal consequences:
o Decreased motility
o Obstruction
o Impaired perfusion

Question 36

Define diverticulitis

Answer 36

Infection of diverticula due to fecal matter stuck in outpouching

Question 37

Clinical manifestations of Diverticular Disease

Answer 37

• Clinical Manifestations: severity depends on extent of infection
o Abdominal pain: left lower quadrant abdominal pain + tenderness
o Fever
o Increase WBC count
o Nausea, Vomiting
o Diarrhea or Constipation
o Less common is right sided abdominal pain: less common R-sided diverticula (highly redundant sigmoid colon)
o Some patients report bleeding from rectum

Question 38

What are the diagnostic tests for diverticular disease

Answer 38

Tests:
o History of Symptoms
o CT scan: very accurate in diagnosing diverticulitis. Images show localized colon wall thickening, inflammation extending into the fat surrounding colon
o Diagnosis of diverticulitis is made confidently when the involved segment contains diverticula
o Other studies such as barium enema, colonoscopy: contraindicative during acute phase d/t risk of perforation
o Physical exam
• Abdominal tenderness
• Distention
o Laboratory analyses
• Bloody stools
• Low hemoglobin and hematocrit indicating anemia
• Complete blood count indicating infection
o Imaging studies
• Inflamed and/or ruptured diverticula

Question 39

How to treat diverticular disease?

Answer 39

• Prevention: most cases of simple, uncomplicated diverticulitis respond well to conservative therapy with bowel rest
o Diet alterations: Low residue diet: low fiber gives colon time to heal
o Lifestyle alterations
o Pharmacologic medications (if bacteria infection is suspected)
• Bulk forming laxatives, antispasmodic
• Treatment
o Management of symptoms
o Control of infection - antibiotics
o Bowel rest
o Prevention of complications
• Peritonitis, abcess, fistula  surgery
o Surgical correction of perforated diverticula (elective)
o Emergency surgery is necessary if intestine has ruptured which always causes infection of abdominal cavity

Question 40

What type of diet is recommended for a PT with diverticular disease?

Answer 40

Low residue diet: low fiber gives colon time to heal

Question 41

What are potential complications of diverticulitis?

Answer 41

• Bacteria may infect outside of colon Inflamed diverticulum bursts opencould cause fatal peritonitis
• Sometimes inflated diverticula can cause narrowing of bowel  obstruction
• Infected part could adhere to bladder, other pelvic organ fistula -abdomen connection between organs (in this case the colon + adjacent organ)
o Bleeding and strictures: an abnormal narrowing of a bodily passage (as from inflammation, cancer, or the formation of scar tissue)

Question 42

What is a “stricture”

Answer 42

an abnormal narrowing of a bodily passage (as from inflammation, cancer, or the formation of scar tissue). This can be an acute complication in diverticulitis.