GI Disease Flashcards
Purpose of the GI Tract
Food digestion and absorption of nutrients and water
Primary disorders of the GI tract are related to:
Damage from gastric acid secretion and abnormal food movement through the GI tract
GI Tract: Route (start to finish)
- Mouth
- Esophagus
- Stomach
- Small intestine
- Large intestine
- Rectum
- Anus
Digestive Process
- Ingestion of food
- Movement of food from mouth to anus
- Secretion of mucus, water and enzymes
- Mechanical digestion of food particles
- Chemical digestion of food particles
- Absorption of digested food
- Elimination of waste products by defecation
GI tract layers- inside to outside
- Mucosa
- Submucosa
- Muscularis
- Serosa or Adventitia
Stomach Secretions
- Acid
- Enzyme (Pepsin)
- Mucus
Layers of Small Intestines (3:4)
- Smooth muscle- Longitudinal & Circular
- Mucosal folds
- Villus- functional unit
- Columnar cells
- Goblet cells
- Microvilli
- Lamina propria
Length of Small Intestine
5 to 6 meters long
Parts of the small intestine
- Duodenum
- Jejunum
- Ileum
Intestinal digestion and absorption- Process
- Initiated in stomach
- Continues in small intestine
- Pancreatic enzymes
- Intestinal enzymes
- Bile salts
- Intestinal motility
- Haustral segmentation
- Peristalsis
- After Breakdown- contents travel to liver via portal vein
- Carbohydrates
- Proteins
- After Breakdown- travel to liver via systemic circulation
- Fats
- Absorption- various GI regions
- Water, vitamins, and electrolytes
Large intestine- Parts
- Cecum
- Appendix
- Colon- Ascending, Transverse, Descending, Sigmoid
- Rectum
- Anal canal- Internal sphincter External sphincter
Length of Large Intestine
1.5M long
Layers of Large Intestine
- Muscle layers
- Longitudinal layers
- Circular layers
- Cell layers
- Columnar epithelium
- Goblet cells
- Arteriole
- Venule
- Lymphatic
Large & Small Intestine Innervation
- Gastrocolic Reflex (preferred pooping time)
- Parasympathetic and sympathetic innervation
- Propulsion
- Water reabsorption
- Sodium reabsorption- Aldosterone
- Relaxation of anal sphincter
- Control to hold and override defecation urge
- Valsalva maneuver function
- Intrinsic innervation of intestines
- Spinal innervation
Referral Patterns Right Upper (3)
- Gallstones
- Pancreatitis
- Stomach Ulcers
Called the Right Hyporchondriac Region
Referral Patterns Right Middle (4)
- Lumbar Hernia
- Urine Infection
- Constipation
- Kidney Stones
Called Right Lumbar Region
Referral Pattern- Right Lower (4)
- Appendicitis
- Constipation
- pelvic Pain (Gynae)
- Inguinal hernia
Called Right Iliac Region
Referral Pattern- Mid upper (5)
- Epigastric Ulcer
- Heartburn (GERD)
- Indigestion
- Pancreatitis
- Stomach Ulcer
Called Epigastric Region
Referral Pattern- Mid-Middle/ center (4)
- Umbelical Hernia
- Pancreatitis
- Inflamed Bowel
- Early Appendicitis
Called Umbilical Region
Referral Pattern- Mid-Lower (4)
- Urine Infection
- Diverticular Disease
- Inflamed Bowel
- Pelvic Pain (Gynae)
Called Hypogastric Region
Referral Pattern- Left Upper (3)
- Billary Colic
- Duodenal Ulcer
- Stomach Ulcer
Called Left Hypochondriac Region
Referral Pattern- Left Middle (3)
- Kidney Stones
- Inflammatory bowel
- Diverticulitis
Called Left Lumbar Region
Referral Pattern- Left Lower (3)
- Diverticulitis
- Inguinal Hernia
- Pelvic Pain
Called Left Iliac Region
Referred pain patterns- pain from the vermiform appendix and colon to the area of sensory distribution for the 11th thoracic nerve
McBurney’s point on Spino-umbilical point - halfway between the ASIS and Umbilicus. usually on the R side. Gentle palpation of McBurney’s point produces pain or exquisite tenderness. Pinch an inch test should also be checked here.
Referral pain patterns- To low back
Mid Abdominal pain caused by disturbances of the small intestine centered around the umbilicus (T9-T11 nerve distribution) can refer to low back at the same anatomical level L3-L4.
Visceral Referred pain- Epigastric Region (8)
- Heart
- Esophagus
- Liver
- Duodenum
- Gallbladder
- Pancreas
- Stomach
- Corresponds to T3 to T5 Sympathetic nerve distribution
Visceral Referred Pain- Periumbilical (5)
- Pancreas
- Small Intestine
- Appendix or
- Proximal Colon
- Corresponds to T9-T11 Sympathetic nerve distribution The umbilicus is in level with the disk located between L3-L4 vertebral bodies.
Visceral Referred Pain- Lower Mid Abdominal/ Hypogastrium region (5)
- Colon
- Large intestine
- Uterus
- Bladder
- Corresponds to T10-L2 Sympathetic N distribution
Referred Pain to Sacrum when Rectum is stimulated
- Pain associated with large intestine and colon,
- May occur in the lower abdomen across either or both abdominal quadrants
Pancreatic Pain (location)
Occurs in Mid line or left of the epigastrium just below the xiphoid process but may be referred to the L shoulder or mid thoracic spine. Posterior pain may radiate or lateralize from the spine away from the mid line. Sensory n distribution is from T5-T9
True/False- You should try to reduce your own hernia
False- Do not attempt to reduce your own hernia you could cause strangulation.
Indirect Hernia- Location
Sac herniates through the internal inguinal ring: can remain in the canal or pass into the scrotum (men) can extend to labia in women
Indirect Hernia- Clinical S&S (3)
- Pain with straining
- Soft swelling that increases with increased intraabdominal pressure.
- May decrease when lying down
Indirect Hernia- Frequency
Most common. 60% of all hernias More common in infants
Indirect Hernia- Causes
Congenital or Acquired
True/False- There are variations in the location of the vermiform appendix
True
When could a negative test for appendicitis using McBurney’s point occur?
When the appendix is located somewhere else other than the end of the cecum. In 50% of the cases the appendix is retrocecal (behind the cecum) or retrocolic (behind the colon)
Another test for appendicitis aside from McBurney’s point
Blumberg’s sign or Rebound Tenderness- assesses appendicitis or generalized peritonitis- press your finger gently but deeply over the R lower quadrant for 15-30 seconds
An alternate test for Blumberg’s Sign
Pinch-an-Inch test- Used to avoid the discomfort of classic rebound tenderness/ Blumberg’s sign. assesses apendicitis and generalized peritonitis
Usually the rebound is the most painful in appendicitis!
Can do a pinch an inch. Take a pinch of skin and let it go – it will recreate that rebound without putting extra pressure on a burst or about-to-burst appendix.
What is Dermatitis Herpetiformis
- A typical grouped pruritic papulovesicles associated with skin reactions from gluten sensitivity.
- Usually occurs on the buttocks, elbows or knees.
- Can affect children but more common in adults between age 30-40.
- It is almost always a sign of celiac disease and usually resolves in 3-6 months with gluten free diet
A herpes virus can also cause a rash that looks like this.
Peptic ulcers- What are they?
Ulcerations of mucosal lining of esophagus, stomach, and duodenum
Pt says: “I’ve got a peptic ulcer” we ask “where?”
Most common sites for peptic ulcer (in picture)
Corresponding pain pattern that goes with them.
Must be confirmed with some type of test. Usually a gastroscope.
Drugs to control gastric Acidity & Secretion are used to treat:
- Peptic ulcers
- May also treat epigastric distress (dyspepsia)
Epigastric distress (dyspepsia)
Leakage of gastric acid into esophagus, gastroesophageal reflux (GERD)
Drugs to control gastric Acidity & Secretion- Antacids
- Neutralize stomach acid, breaking it down into salt and water
- Have a carbonate or hydroxide base combined with aluminum, magnesium, sodium, or calcium
- Aluminum may give some protection against Helicobacter pylori
- Biggest adverse effect is constipation
- Antacids should not be taken within 2 hours of orally administered drugs that need gastric juices to dissolve them, such as warfarin, digoxin, iron supplements, and certain antibiotics (tetracyclines, fluoroquinolones, ketoconazole)
Drugs to control gastric Acidity & Secretion- H2 Receptor Blockers (Tagamet, Pepcid, Axid, Zantac)
- Histamine receptors that diminish stomach parietal cells secretion of gastric acid
- Can decrease damage from NSAIDs
- Used for short and long-term management of peptic ulcer and GERD
- Generally well tolerated
- Headache and dizziness may occur
**
This is one of 2 classes of drugs for people who have had to take tums all the time.
Tagamet and Pepcid were like a miracle drug when it first came out.
Most of the time people do not have any trouble of this
Most of these are available over the counter at about half the pharma dose
Drugs to control gastric Acidity & Secretion- Proton Pump Inhibitors (Nexium, Prevacid, Prilosec, Protonix)
- Inhibit the enzyme responsible for secreting gastric acid
- H+, K+-ATPase, known as the “proton pump”
- Can decrease acid secretion 80-95% and may have some protective effect against H. Pylori, making this the drug class of choice for long-term management
These are like the Cadillac of gastric acid control drugs
Note on drug classes: Insurance formularies usually determine which class a person can take. These are not equivalent, but insurance companies still treat them as such. But if person is not responding to one type, MD can write an override for a different formulary. pts can tell you very well if it is working or not.
PPI (Proton Pump Inhibitors) Effects
- May have acid rebound when discontinued
- May have ↑ risk of C. Difficile
Rebound effect: If pt decides to just quit, they may have acid rebound because their body has adjusted to what the meds do.
Treatment of H Pylori
- Several treatment protocols, all use multidrug therapy
- Usually consists of mixture of antibiotics and PPIs
- Administered for 10-14 days,
- Maintenance on a PPI
MDs get their own concoctions that they like. Figuring out the connection between H. pylori and ulcers has been wonderful!
Other GI Medications (3)
- Reglan – a dopamine receptor that is useful to stimulate GI motility
- Cytotec – prostaglandin, treatment of ulcers
- Carafate, Sulcrate – ulcer treatment, coats the stomach mucosa
- You’re probably familiar with… Anti-diarrheal agents Laxatives and cathartics Emetics, antiemetics
What is something with the iliopsoas that could cause pain in the pelvic viscera?
Shows the proximity of the iliopsoas and why abscess there can disturb viscera.
what are the five most common areas to have an abdominal hernia?
Direct Inguinal
Indirect Inguinal
Umbilical
Femoral
Incisional
What are the two Esophageal sphincters, and what could go wrong with them?
Upper and Lower
Could stick together or fibrosis there. Get Strictures that make it hard to swallow.
- We may have to have a gastroscope to stretch them out
Lower: – get reflux (increasingly common – more aware of it and more weight)
What are the three arteries in the portal system?
- Celiac Artery
- Superior Mesenteric Artery
- Inferior Mesenteric Artery
Where do water, vitamins, and electrolytes mostly get absorbed?
Water, vitamins, and electrolytes are more absorbed in large intestine
What should we do with a pt that is presenting with pain in a non-MSK pattern?
If has not been examined, send for referral.
If it has been examined, we should understand that MSK intervention will not be terribly effective. We should be looking more at pt ed, general conditioning, etc.
Who has a very high risk for abdominal hernias?
People who have had gut surgery are at very high risk for abdominal hernias.
Pts often do not understand how fragile the ab wall could be after surgery
Too often the MD says you can go back to your life with no limitations (without asking what the pt normally does)
Often we need to be very specific about what not to lift with pt (give them an example of the max weight they can lift that they encounter in daily life and is something they are familiar with)
T/F: Any weak points in the abdominal wall can present the opportunity to have a hernia
true
What is a relationship between hernias and postpartum women?
Post partum women can find they have weakness in fascia next to the rectus abdominus that can cause a hernia.
what might make appendicitis worse?
eating
what is something bad that can happen to the pyloric sphincter?
What can be done about it?
Senosis here (from hypertrophic sphincter) can be treated with a scope that puts in a stent (or we can just stretch it with the scope).
Electrolyte Sport drinks vs water
dr. T said that sometimes when a pt is recovering from or experiencing some sort of gastointenstinal upset, they drink water to help replace the lost liquid, but they may still feel poorly.
She has found that just reccomending a sports dring with electrolyts can make a big difference and help them feel better (recover faster).
