Gastrointestinal System Disorders

Question 1

Beginning and ending of GI tract = ?

GI System Disorders

Answer 1

GI Tract:

• Is a long tube, beginning at esophagus and ending at rectum.

Question 2

(a) Upper GI includes = ?

(b) Middle GI includes = ?

(c) Lower GI includes = ?

(stomach, jejunum, cecum…etc.)

GI System Disorders

Answer 2

(a) Upper GI:

• Mouth
• Esophagus
• Stomach

(b) Middle GI:

• Duodenum
• Jejunum
• Ileum

(c) Lower GI:

• Cecum
• Colon
• Rectum

Question 3

Accessory GI organs include = ?

GI System Disorders

Answer 3

Accessory organs:

• Salivary glands
• Liver
• Pancreas

Question 4

Function of GI wall structure = ?

GI System Disorders

Answer 4

GI Wall Structure:

• Digestion
• Absorption.

Question 5

Layers of GI Wall Structure:

• Mucosa = ?
• Submucosa = ?
• Muscularis = ?
• Serosa = ?

GI System Disorders

Answer 5

Layers of GI Wall Structure:

(a) Mucosa:

• Made of epithelium
• Secrete mucus, enzymes, and hormones, absorption.
• Think
• • Inflammatory Bowel Disease (IBD) = Crohn’s disease, ulcerative colitis
• • Peptic Ulcer Disease: Ulceration of the mucosal lining, often caused by prolonged NSAID use.

(b) Submucosa:

• Thin connective tissue layer that has nerves, glands and blood vessels.
• Think =
• • Gastroesophageal Reflux Disease (GERD), Submucosal inflammation due to chronic exposure to gastric acid reflux.
• • Irritable Bowel Syndrome (IBS): Submucosal alterations and neuroimmune dysregulation

(c) Muscularis:

• Smooth muscle cells- facilitate the movement of contents of GI tract
• Think =
• • Gastric Motility Disorders (gastroparesis)
• • Intestinal Obstruction: Impaired muscularis function

(c) Serosa:

• Serous membrane
• Consist of simple squamous epithelium and connective tissue (also known as visceral peritoneum).
• Think =
• • Diverticulitis: Inflammation and infection involving the serosa layer.
• Peritonitis: Infection or inflammation of the serosal membrane covering the abdominal cavity.

Question 6

Signs and symptoms of GI diseases = ?

GI System Disorders

Answer 6

• Nausea
• Vomiting
• Diarrhea
• Anorexia
• Abdominal pain
• Referred pain
• Arthralgia (joint stiffness)
• Dysphagia (difficulty swallowing)
• Weight loss
• GI bleed
  Heart burn
• Epigastric pain
• Felt in midline below sternum
• Cause: acidic contents of stomach move backward into esophagus

Fecal incontinence (inability to control bowel movements):

• Psychological cause
• Neuro sensory motor impairment (stroke, SCI)
• Anal distortion - secondary to traumatic childbirth, sexual assaults

GI Bleed:

• Coffee ground emesis (coffee or dark brown vomitus, granular material, resemblescoffee ground)
• Hematemesis (bright red blood)
• Melena (black tarry sticky stools)
• Hematochezia (maroon coloredstools).

Question 7

Signs and symptoms of GI dieases:

• Constipation = ?
• Neurogenic = ?
• Metabolic and/or Endocrine = ?
• Mechanical = ?
• Drugs = ?

GI System Disorders

Answer 7

Signs and Symptoms of GI diseases - Constipation:

• Pressure on sacral nerves from stored fecal content (aching in sacrum, buttocks andthighs).
• Acute / chronic diseases of GI

Neurogenic:

• MS
• Parkinson’s
• SCI

Metabolic / Endocrine Defects:

• Hyperparathyroidism
• Hypothyroidism
• Severe malnutrition.

Mechanical:

• Bowel obstruction, cancer, diverticulitis, pregnancy,pelvic floor andanal sphincter dysfunction (analsphincter contracts instead of relaxing)
• Dehydration, prolonged bed rest, emotional stress
• People with mechanical low back pain can develop constipationbecause ofmuscleguarding and splinting- reduced bowel motility

Drugs and diet:

• Anesthetic agents, antacids, antidepressants, antipsychotics, antihistamine, cancer chemotherapy, iron compounds, narcotics, lack of dietary fiber.

Question 8

GERD = ?

GI System Disorders

Answer 8

Gastroesophageal reflux disease (GERD):

• GERD can lead to mucosal damage.
• Backward flow of stomach contents and acids like pepsin/bile into the esophagus or beyond like larynx, a phenomenon called acid reflux.
• Normally high pressure zone exist around the gastroesophageal sphincter, which permits passage of food and liquids and prevents reflux.
• Reduction in pressure of LES (lower esophageal sphincter) or increased gastric pressure or gastric contents can lead to esophageal reflux.
• GER that occurs more than 2 times/ week for a few weeks can lead to GERD.
• HCL / gastric/ duodenal contents containing bile acid and pancreatic juice come in contact with walls of esophagus.
• Reflux esophagitis (most common type of esophagitis), defined as inflammation of esophagus.
• Mucosal ulcerations - that may bleed
  Granulation / healing- scarring- esophageal strictures.
  Narrow the esophagus making swallowing difficult.

Complications:

• Vocal cord inflammation, asthma, esophageal cancer

Question 9

Causes GERD = ?

GI System Disorders

Answer 9

(a) Decreased pressure of lower esophageal sphincter

• Chocolate, fatty foods, citrus products, coffee, alcohol, carbonated drinks, cigarette smoking
• Medications like morphine, calcium channel blockers, tricyclic antidepressants, estrogen therapy
• Pregnancy, last semester: increased progesterone relaxes the sphincter

(b) Increased gastric pressure

• Pregnancy: increased gastric pressure
• Obesity
• Tight clothing: spandex

(c) Gastric contents near junction

• Recumbency
• Increased intra-abdominal pressure

Question 10

Clinical manifestations of GERD = ?

GI System Disorders

Answer 10

Clinical manifestations - GERD:

• Heart burn: Burning sensation in the retrosternal area (Often at night)
• Pain: located in the epigastric area / retrosternal area, may radiate to neck, jaw, back.

Notes:

• Occurs 30-60 minutes after a meal
• Sour taste - acid regurgitation (perception of flow of refluxed gastric contents into the mouth)
• Made worse by bending at waist and recumbancy, relieved by sitting upright
• Severe reflux; reaches pharynx and mouth
• Laryngitis and morning hoarseness
• Cough
• Asthma
• Pulmonary aspiration in neurologically impaired
• Recurrent pulmonary aspiration- aspiration pneumonia.

Question 11

Clinical manifestations of GERD:

• Complications = ?

GI System Disorders

Answer 11

Complications:

(a) Barret’s esophagus:

• Metaplasia: squamous lining of lower esophagus to columnar epithelium
• Can become cancerous

(b) Cause:

• Cycle of mucosal damage that leads to erosion, edema, scar tissue.
• Dysphagia (edema, spasm and scars)
• Painful swallowing

Question 12

How to diagnose GERD = ?

GI System Disorders

Answer 12

diagnose GERD:

(a) History

(b) Esophagoscopy:

• Allows visualization of lumen of upper GI tract.
• Permits performance of biopsy.

(c) pH monitoring

Question 13

GERD Management:

• Drugs = ?
• Lifestyle modifications = ?

GI System Disorders

Answer 13

Drugs:

• Proton pump inhibitors: cut acid production (E.g. Prilosec).
• Histamine 2 receptor blocker: reduces acid production (E.g. Zantac)
• Antacids: neutralize and reduce stomach acid (E.g. Tums)
• Prolonged use cause body’s phosphate levels to reduce.

Lifestyle modifications / PT:

• Avoid food that reduce the lower esophageal sphincter tone: caffeine, nicotine, NSAIDS, chocolate, fried and fatty foods.
• Acidic foods like orange juice, wine, tomatoes may irritate the inflamed esophagus.
• Avoid alcohol and smoking
• Keeping food diary: identify triggers
• Remaining upright after meals for several hours, avoiding large meals near bedtime.
• Elevation of head of bed at least 6 inches to reduce nocturnal reflex.
• Excess abdominal fat puts pressure on stomach - weight loss.

Question 14

Inflammation of vermiform appendix= ?

GI System Disorders

Answer 14

Appendicitis:

• Inflammation of vermiform appendix.
• Occurs in adolescents and young adults.
• Cause blockage, infections
• Appendix becomes obstructed, inflamed and infected, rupture may occur leading to peritonitis, medical emergency
• Peritonitis (membrane lining the cavity of the abdomen and covering the abdominal organs)
• Pain (begins in umbilical region and localizes to right lower quadrant), nausea, vomiting, low grade fever
• Pain could be referred to thigh
• Pain in groin/ testicular area in young males
• Pain comes in waves, becomes steady, aggravated by movement causing client to bend over or draw the legs up to relieve abdominal muscle tension.

Question 15

Appendicitis:

• Rebound tenderness = ?
• Rovsing’s sign = ?

GI System Disorders

Answer 15

Appendicitis:

Rebound Tenderness:

• Press your fingers gently and deeply over right lower quadrant for 14-30 secs, palpating hand is then quickly removed.
• Pain is induced by quick withdrawal,pain from rapid movement of inflamed peritoneum, pain on the side of inflammation.

Rovsing’s sign:

• Palpation of left lower quadrant of abdomen increases pain felt in the right lower quadrant.

Question 16

McBurney’s Point = ?

GI System Disorders

Answer 16

Appendicitis - McBurney’s Point:

• Inflammation of peritoneum in acute appendicitis or from other inflammatory infectious causes.
• Client in fully supine position
• Palpate ASIS and umbilicus, tenderness on palpation halfway between the umbilicus and ASIS.
• Can be very painful when positive, so do pinch an inch test first

Appendicitis Testing Video

Question 17

Pinch an Inch Test = ?

GI System Disorders

Answer 17

Appendicitis - Pinch an Inch Test:

• To avoid the discomfort of the classic rebound tenderness test, the pinch-an-inch test is recommended to assess for appendicitis or generalized peritonitis.

(B) Test:

• To perform the test, a fold of abdominal skin over McBurney’s point is gently grasped and elevated away from the peritoneum.
• The skin is then allowed to recoil back against the peritoneum quickly.
• If the individual has increased pain when the skin fold strikes the peritoneum (upon release of the skin), the test is positive for possible peritonitis.

Question 18

Psoas Sign = ?

GI System Disorders

Answer 18

Psoas Sign:

• Performed when abdominal pain is possible cause of hip or thigh pain, when abscess forms on the iliopsoas muscle from an inflamed / perforated appendix, inflamed peritonitis, osteomyelitis of ileum / vertebrae or septic arthritis of SI joint, direct extension of intra-abdominal infections like diverticulitis, Crohn’s disease, kidney infection.
• Fever, lower abdominal, pelvic and back pain, or referred pain to hip, medial thigh and groin
• Antalgic gait - functional hip contracture
• Pain with hip extension
• Tender mass can be palpated in the groin.
• In the supine position, have the client activelyperform a straight leg raise; apply resistance to the right distal thigh as the clienttries to hold the leg up or side lying and right hip extension.
• Increased abdominal,flank, or pelvic pain constitutes a positive sign,suggesting irritation of the psoas muscle, inflamed appendix orperitoneum.

Question 19

Inflammatory bowel disease

GI System Disorders

Answer 19

Inflammatory bowel disease:

• Refers to chronic inflammatory condition, commonly in large and small intestine, can occur anywhere along the GI tract from mouth to anus.

Most common forms include

• Crohn’s disease
• Ulcerative colitis

Peak incidence:

• 15-35 years
  Over 1 million in US
  No proven cause
  Genetic suggested

Question 20

Etiology and Pathogenesis - Inflammatory Bowel Disease:

• Genetic susceptibility = ?
• Environmental triggers= ?
• Systemic manifestations = ?

GI System Disorders

Answer 20

(a) Unregulated and exaggerated immune response.

(b) Genetic susceptibility

• First degree relatives of people diagnosed have 30-100 times greater incidence
• Largest genetic association study employed genetic wide association data for over 75000 people with IBD- 163 susceptible loci for IBD

(c) Environmental trigger

• Smoking- 2-fold risk

(d) Systemic manifestations:

• Arthritis in spine and sacroiliac joints inflammatory conditions of eye, skin lesions, autoimmune anemia

Question 21

Crohn’s disease = ?

GI System Disorders

Answer 21

Crohn’s disease:

• Chronic, recurrent lifelong disorder, characterized by granulomatous inflammatory process.
• Can be found anywhere along the GI tract, but small intestine and ascending colon are more commonly affected.
• Characterized by diseased area of intestine with normal intestine in-between (skip lesions).
• Periods of exacerbation and remission.
• Common in 20’s and 30’s , slightly more common in women.

Question 22

Crohn’s Disease:

• Layer most affected = ?
• Damage to villi = ?

GI System Disorders

Answer 22

Crohn’s Disease:

• All the layers are involved, submucosal layer is affected the most
• Inflammation - granuloma inflammation
• Edema / fissures - cobblestone appearance
• Fibrosis, bowel obstruction - life threating emergency
• Ulcerations - deep - penetrate through layers and form fistula, base of fistula can have abscess.
• Damage to villi = impairs absorptive capacity, malnutrition.

Question 23

Fever with acute inflammation, diarrhea, abdominal pain, weight loss, fluid and electrolyte disorders are signs and symptoms of = ?

GI System Disorders

Answer 23

Crohn’s Disease:

• Periods of exacerbation and remission, symptoms related to location of lesion.
• Fever with acute inflammation, diarrhea, abdominal pain, weight loss, fluid and electrolyte disorders.
• Terminal Ilium:Pain in the periumbilical region with possible referred pain to the corresponding segment of the low back pain.
• Nutritional deficiencies- in childhood- retardation of growth

Complications:

• Fistula formation, abdominal abscess.
• This condition comes and goes with the disease process and may precede repeat episodes of bowel symptoms by 1-2 weeks.
• Anti-inflammatory& Nutritious diet(avoid fat).

Question 24

Ulcerative Colitis = ?

GI System Disorders

Answer 24

Ulcerative Colitis:

• Chronic inflammatory disorder of mucosa primarily and submucosa of the rectum/colon.
• Confined large intestine: rectum and colon; begins in rectum and spreads proximally.
• No skip lesions
• 15-25 years of age
• Mucosa bleeds, erythema, can form abscess.
• Inflammation causes pseudo polyps.
• Cells atrophy
• Metaplasia: High risk of colorectal cancer.

Question 25

Ulcerative Colitis: * Clinical manifestations = **?** ## Footnote *GI System Disorders*

Answer 25

[**Ulcerative Colitis**](https://www.crohnscolitisfoundation.org/what-is-ulcerative-colitis#:~:text=Ulcerative%20colitis%20is%20a%20chronic%20inflammation%20of,ulcers%20due%20to%20an%20overactive%20immune%20response.) - Clinical manifestations: * Diarrhea * Rectal bleeding * Nausea * Vomiting * Anorexia * Weight loss * Fever **Rare**: * Anemia * Clubbing of fingers  * Extra-intestinal manifestations ## Footnote (a) **Diarrhea**: * <4 to 10 or more stools/ day  * Persist for days, weeks or months and then subside to reoccur later  (b) **Rectal bleeding**: stool contain blood 

Question 26

Pathophysiology: * Crohn’s and Ulcerative Colitis ## Footnote *GI System Disorders*

Answer 26

**Crohn's Disease**: * Location = Small intenstine and ascending colon. * Pattern = Skip lesions * Depth = Primarily submucosal * Diarrhea = Watery * Abdominal pain = Yes * Bowel obstruction = Comon * Cancer risk = Increased **Ulcerative Colitis**: * Location = Descending colon * Pattern = Continuous * Depth = Primarily mucosal * Diarrhea = Bloody * Abdominal pain = Yes * Bowel obstruction = Uncommon * Cancer risk = Higher risk than with Crohn's

Question 27

Diverticulosis = **?** ## Footnote *GI System Disorders*

Answer 27

**Diverticulosis**: * **Diverticulum**: Outpouching in the wall of the colon, without inflammation. * Develops at the site of weakness in the intestinal wall. * More than one diverticulum is called **diverticula**. * Presence of diverticula is called **diverticulosis**.

Question 28

Diverticulitis = **?** ## Footnote *GI System Disorders*

Answer 28

**[Diverticulitis](https://www.mayoclinic.org/diseases-conditions/diverticulitis/symptoms-causes/syc-20371758#:~:text=Diverticulosis%20occurs%20when%20small%2C%20bulging,lining%20of%20your%20digestive%20system.)**: * When food particle/ feces become trapped, pockets become inflamed. * Pain and tenderness in the lower left quadrant (sigmoid colon), accompanied by nausea and vomiting, slight fever and elevated WBC’s. **Complications**: * Herniation * Perforation * Hemorrhage * Inflammation. * The presence of diverticula is known as **diverticulosis**. * When one or more of the pouches become inflamed, and in some cases infected, that condition is known as **diverticulitis**.

Question 29

Diverticular disease: * Etiology & risk factors ## Footnote *GI System Disorders*

Answer 29

Diverticular Disease - Etiology & Risk factors: * Primary risk factor, low fiber diet which decreases stool bulk - predisposing to constipation. * Chronic constipation * Atrophy/weak bowel muscle  * Obesity * Weak pelvic floor muscles (constipation) * Inherited defect in the muscular wall of intestine * NSAIDS, acetaminophen - associated with diverticular disease

Question 30

Diverticular disease: * Treatment ## Footnote *GI System Disorders*

Answer 30

Diverticular disease - Treatment: * **Immediate**: control of infection, resting of bowel, prevention of complications  * Acute dietary management: clear liquid diet for 2- 3 days until symptoms resolve Diet and lifestyle to prevent constipation * Diet high in fiber and low in fat * Avoidance of foods like banana and rice * Fluid intake, 2 L/day  * Daily exercise  **Pharmacotherapy**: * Anti-biotic & anti-inflammatory **Surgical**: * Surgery for perforations * Bowel resections or removal of portion of large intestines. * **Colostomy**: establishment of an artificial opening of the large intestine externally on the abdomen until the colon is healed)

Question 31

# Diverticular Disease - Primary pain: Pain at #1 = **?** ## Footnote *GI System Disorders*

Answer 31

(**1**) * Stomach * Duodenum

Question 32

# Diverticular Disease - Primary pain: Pain at #2 = **?** ## Footnote *GI System Disorders*

Answer 32

(**2**) * Liver * Gallbladder * Common bile duct

Question 33

# Diverticular Disease - Primary pain: Pain at #3 = **?** ## Footnote *GI System Disorders*

Answer 33

(**3**) Small intestine

Question 34

# Diverticular Disease - Primary pain: Pain at #4 = **?** ## Footnote *GI System Disorders*

Answer 34

(**4**) Appendix

Question 35

# Diverticular Disease - Primary pain: Pain at #5 = **?** ## Footnote *GI System Disorders*

Answer 35

(**5**) Esophagus

Question 36

# Diverticular Disease - Primary pain: Pain at #6 = **?** ## Footnote *GI System Disorders*

Answer 36

(**6**) Pancreas

Question 37

# Diverticular Disease - Primary pain: Pain at #7 = **?** ## Footnote *GI System Disorders*

Answer 37

(**7**) * Large intestine * Colon

Question 38

# Referred Pain Pain at #1 = **?** ## Footnote *GI System Disorders*

Answer 38

(**1**) * Liver * Gallbladder * Common bile duct

Question 39

# Referred Pain Pain at #2 = **?** ## Footnote *GI System Disorders*

Answer 39

(**2**) Appendix

Question 40

# Referred Pain Pain at #3 = **?** ## Footnote *GI System Disorders*

Answer 40

(**3**)  Pancreas * The exocrine pancreas produces enzymes that help to digest food, particularly protein. * The endocrine pancreas makes the hormone insulin, which helps to control blood sugar levels.

Question 41

# Referred Pain Pain at #4 = **?** ## Footnote *GI System Disorders*

Answer 41

(**4**) Pancreas

Question 42

# Referred Pain Pain at #5 = **?** ## Footnote *GI System Disorders*

Answer 42

(**5**) Small intestine

Question 43

# Referred Pain Pain at #6 = **?** ## Footnote *GI System Disorders*

Answer 43

(**6**) Colon

Question 44

# Referred Pain Pain at #7 = **?** ## Footnote *GI System Disorders*

Answer 44

(**7**)  Esophagus

Question 45

# Referred Pain Pain at #8 = **?** ## Footnote *GI System Disorders*

Answer 45

(**8**) (a) **Stomach** * Primary function is to break down food both mechanically (through muscular contractions) and chemically (through the action of gastric juices), turning it into a semi-liquid substance known as chyme. (b) **Duodenum** * First part of the small intestine, situated immediately after the stomach. * Plays a crucial role in digestion, where the chyme from the stomach mixes with bile from the liver and digestive enzymes from the pancreas. * Bile aids in the breakdown of fats, while pancreatic enzymes help further digest proteins, carbohydrates, and fats.

Question 46

# Referred Pain Pain at #9 = **?** ## Footnote *GI System Disorders*

Answer 46

(**9**) * Liver * Gallbladder * Common bile duct

Question 47

# Referred Pain Pain at #10 = **?** ## Footnote *GI System Disorders*

Answer 47

(**10**) * Stomach * Duodenum