GI Disorders Flashcards
Peptic Ulcer Disease
A peptic ulcer is a _____ in the protective _____ lining of the (3)
These breaks expose the _____ to gastric _____ cause _______
Ulcers can be
_____ or _____
Superficial (1) or Deep (1)
break in mucosal lining of lower esophagus, stomach, or duodenum
expose submucosa to gastric secretions cause autodigestion
Acute or Chronic
Erosions or True Ulcers
3 Places we can find Peptic Ulcers
(1) from reflux
(1) where highest concentration of HCL found
(1) MOST COMMON, unlike stomach does not have alkaline mucus covering lining and receives acidic contents from stomach so particularly vulnerable to ulceration
Lower Esophagus
Antrum of Stomach
Duodenum
Erosion
=
Symptoms?
Not true ulcers, penetration of only the superficial layer, underlying muscle and blood vessels intact
Mostly Asymptomatic bc HCL is not interactin with nerves in muscle layer yet
Acute Ulcer
=
Penetration through submucosa and into muscle layer
Perforating Ulcer
=
When an ulcer penetrates through all the layers of the GI tract - dangerous bc potentially exposes body cavity to all contents of the tract
Risk Factors for Peptic Ulcer Disease
- S______
- ______ infection
- Habitual use of (1)
- A______
- High ______ Stress
- Chronic diseases such as (3)
- Smoking
- H. Pylori
- NSAIDS
- Alcohol
- Psychological Stress
- Emphysema, Rheumatoid arthritis, Cirrhosis
Chronic diseases (all inflammatory in naure) can cause PUD from either increase in gastric acid production and/or of inflammation that causes damage to mucosal lining
More about H. Pylori
- Found in the stomach of __% of all humans
- In most people there are __ symptoms, but the bacterium can trigger ulcers in __-__% of those infected
- The bacteria is thought to cause more than __% of duodenal ulcers and __% of gastric ulcers
Thought to trigger ulcers by stimulating ____ production in stomach and/or by triggering local _____ (______) responses
- 50%
- no symptoms, 10-15%
- 90%, 80%
acid production, immune (inflammatory) response
Contributes to stress or potential injury of mucosal lining and if you have underlying risk factors can help push you over the endge to develop ulcers
3 Ways H. Pylori Causes Peptic Ulcers
- Presence of H. Pylori in the stomach (1) could be dt release of bacterial toxins or irritation of mucosal lining
- If detected by person’s (1) that then damages mucosal lining
- (1) released by H. Pylori can irritate mucosal lining
- Increases gastric acid production
- Immune system can trigger local inflammatory response
- Bacterial toxin
Pathophysiology of Esophageal Reflux Disease
- ______ gastric emptying
- Increased frequency of transient LES (lower esophageal sphincter) ______
- Increased ______
- Loss of secondary ______ following transient LES relaxations
- Decreased LES _____
- >
- Initial esophageal lesion -> scar -> incompetent LES -> _______ injury
- >
- St_____, P_____, Ob______, Pe_______
- _____ Esophagus -> _______
- Delayed
- relaxations
- acidity
- peristalsis
- tone
- recurrent
- Stricture, Pain, Obstruction, Perforation
- Barrett’s -> Cancer
Duodenal Ulcers
_____ frequently seen type of ulcer
Contributing factors may include
- Hypersecretion of (2)
- S_____, _____ infection, excess _____ cells, etc
- Elevated plasma (1) levels
- Inadequate secretion of pancreatic (1)
- Excessively rapid gastric ______
- _____ reaction to H. Pylori infection
Most
-
gastric acid, pepsin
- Smoking, H.Pylori, parietal
- Gastrin
- sodium bicarbonate
- emptying
- Immune
Duodenal Ulcers (Notes)
Most common, unlike stomach does not have thick alkaline mucus covering lining and recieves acidic contents from stomach so particularly vulnerable to ulceration
- Excess parietal cells bc those are the cells that produce ___
- Gastrin is a hormone released by stomach that stimulates production of (2)
- If stomach empties too fast, doesn’t give duodenum enough to _____ the acid
- Again immune reaction causes _______ response
- HCL
- gastric acid and pepsin
- neutralize
- inflammatory
Duodenal Ulcers Continued
Once chyme enters duodenum, presence of acid triggers duodenal mucosal cells to release (2) -> both hormones act on liver and pancrease to release bile and digestive juices into duodenum
- Secretin acts on _____ portion of pancreas on ____ cells to release _____ solution -> to neutralize acid coming from stomach -> so pretty much duodenum doesn[t have thick alkaline mucus it depends on the sodium bicarbonate solution coming from pancreas
CCK, Secretin
- exocrine, duct, alkaline
Duodenal Ulcers
The characteristic manifestation of a duodenal ulcer is ____ _____ pain in the _____ region
What type of pattern?
Duodenal ulcers often heal ______ but reoccur within _____
Chronic intermittent pain in epigastric region
Food pain relief = consuming food triggers acid production by stomach which triggers pain, but then consuming mor food can alleviate the pain bc it gets between the acid and the ulcer (experienced by both gastric and duodenal ulcers)
Spontaneously
Timing of Food Pain Relief for Duodenal Ulcers
When does the person feel pain after eating?
When will ther person feel pain relief from eating more food?
90 min after eating when food and acid hits duodenum
20-30 min after consuming more food bc food gets in between acid and ulcer
Timing of Food Pain Relief in Gastric Ulcers
When does the pt feel pain after eating?
When is the pain relieved when pt eats more food?
No pain immediately bc food gets in between acid and ulcer, 20-30 min after when food moves out of the stomach
Immediately once you eat more food and enters stomach, then again 20-30 min will feel pain
Duodenal and Gastric Ulcer Treatments
(1) includes histamine blockers block histamine or receptors in stomach bc histamine in stomach stimulates acid production
(1) proton pumps move H+ out of parietal cells into stomach where it binds to CL to make HCL - directly blocks production of ____ (ex _____)
(1) for _____ infection
(1) drugs to inhibit secretion, suppress gastric motility, delay gastric emptying
Antacids
Proton Pump Inhibitors - HCL (omeprazole)
Antibiotics H.Pylori
Anti-cholinergics
Stress Ulcers
An acute form of peptic ulcers that tend to accompany severe _____, systemic ____, or ____ injury
Usually involves _____ sites distributed throughout stomach and duodenum
Stress ulcers are essentially _____ ulcers
illness, trauma, neural injury
multiple
Ischemic ulcers
Stress Ulcers
= NOT ______ but a stress _____ ulcer
_____ Stimulation -> Decreased (1) -> (1) Declines -> Decreases (1) -> Exposes mucosa to (1) -> (1)** from _______**
Ex) (1) = type of stress ulcer that is very severe and involves trauma to part of the brain where vagal nerves originate -> ischemic stress response + intense activation of vagus nerve that stimulates gastric acid prudction
Psychological, response
Sympathetic -> blood flow to mucosal lining -> mucosal metabolism -> mucus production -> gastric acid -> AUTODIGESTION and ulcer formation from ISCHEMIA
Cushing’s Ulcer
Disorders of Maldigestion and Malabsorption
(3)
Interference with nutrient digestion or absorption in the?
Malabsorptive and Maldigestive disorders often?
- However there are primary malabsorptive conditions -> involves something that kills _____ cells/vili and reduces _____ ___
Pancreatic Insufficiency
Bile Salt Deficiency
Lactase Deficiency
small intestine
occur together
- kills mucosal cells, reduces absorptive SA
Pancreatic Insufficiency
=
Caused usually by pancreatic diseases like (2)
Clearest signs is the presence of large amount of ___ in the stool (1) and (1)
A deficient production of pancreatic enzymes (Lipase, Amylase, Trypsin, Chymotripsin, Carboxypeptidase)
Pancreatitis, Pancreatic carcinoma
fat in stool, Steatorrhea, weight loss
Pancreatic Insufficiency (Notes)
Pancreas is important in breaking down every category of food but especially ___ bc pancreas supplies our only form of _____
- Not being able to digest fat can have devestating effects bc fat is our most (1) food
- So clearest signs of pancreatic insufficiency = ____ loss, body _____, steatorrhea (foul ____, very ____, may _____)
fat, pancreatic lipase
- most calorically dense food
- weight loss, body wasting, steatorrhea (foul odor, very oily, may float)
Bile Salt Deficiency
Certain conditions decrease production of bile by the liver (2)
Clinical Manifestations of bile salt deficiency are related to poor intestinal ______ of?
- When present alone will not effect fat digestion to the same degree as pancreatic deficiency -> no steatorrhea but stool will be abnormal, what does it look like? why?
Advanced liver disease (Cirrhosis), Obstructions of the bile ducts
poor absorption of fat and fat soluble vitamins (A, D, E, K)
- clay/gray colored stool bc bilirubin in bile is what makes feces brown
Bile Salt Deficiency Clinical Manifestations
- Vitamin A: associated with night ________
- Vitamin D: associated with decreased ______ absorption with bone ______ (osteoporosis), bone ____, and f_______
- Vitamin K: associated with ______ Prothrombin time, leads to spontaneous ______
- Vitamin E: may cause ________ effects in ________
- blindness
- calcium, demineralization, bone pain, fractures
- prolonged PT, bleeding
- neurological, children
Manifestations rt poor absorption of fat soluble vitamins = so remember bile doesn’t digest fat but emulsifies fat so in absence, fat soluble vitamins get trapped in large lobules of fat and we can’t access them
Lactase Deficiency
Very common mal_____ deficiency AKA Lactose Intolerance
Lactase = one of the ______ enzymes bound to mucosal cells on the (1) membrane of the ______ in the small intestine
- Ability to produce lactase beyond weaning is a ______ trait, but the dominant trait in humans is to have a progressive decline ability to produce lactase beyond childhood (dt idea of having weaned off mother’s milk and no more need to consume dairy)
- Recessive trait has evolved to be more common dt rise in ______, domestication of _____, and consumption of dair products
- Common in (2) descent
maldigestive
disaccharide enzyme, brush border, microvilli
- recessive
- agriculture, animals
- African, middle eastern
What happens in Lactose Deficiency
Consume dairy products -> lactose moves through small intestine and enters large intestine _______ where it gets consumed by _____ of the colon -> consumes it by _______ -> byproduct is _____
- _____/gassy _____
- f_______
- Increased lactose in feces increases _____ so you get (1)
Cultured dairy?
enters undigested, bacteria, fermentation, gas
- painful/gassy cramps
- flatulence
- osmolarity, osmotic diarrhea
Cheese and yogurt easier to digest vs. milk bc milk in cheese and yogurt have incorporated with nonharmful bacteria that has broken down some of the lactose in the milk
Inflammatory Bowel Disease
(2)
Chronic _______ conditions that lead to _______ effecting the (1) in UC and Chron’s can effect ______ along the GI tract with some parts being more effected than others
Many ______ and distinct ________
Etiology: ______ disorders, has a ______ component (esp Crohns)
Ulcerative Colitis
Crohn’s Disease
Chronic inflammatory conditions, lead to ulcerations, colon, anywhere
similarities, differences
Autoimmune, hereditary
Ulcerative Colitis vs. Crohn’s Disease
-
Site involved
- UC =
- Crohn’s =
-
Depth of Ulcers
- UC =
- Crohn’s =
-
Pattern of Ulcerations
- UC =
- Crohn’s =
-
Site
- Only colon
- Entire GI tract (mouth anus)
-
Depth
- Shallow (mucosa)
- Deep, sometimes penetrating
-
Pattern
- Continuous
- Patchy, skip lesions
UC (Notes)
- Site involved: only _____ usually ____ and ____ colon more common
- Depth of Ulcer: starts in ____ and tends to be _____
- Pattern of Ulceration: ______ often starts in rectum or signmoid colon and spreads to involve more colon - whatever portin the entire surface is effected (not patchy)
- colon, rectum, sigmoid
- mucosa, shallow
- continuous
Crohn’s (Notes)
- Site involved: can have ____ ulcerations, _____ disease, and anywhere in between
- Depth: start in submucosa and tend to be ______
- Pattern of Ulceration: _____, ____ lesions
- mouth, perianal
- penetrating
- patchy, skip
Ulcerative Colitis Manifestations
A chronic (______) inflammatory disease that causes ulceration of the colonic mucosa - usually the rectum and sigmoid colon
Most patients at first presentation of UC have ____ sx, 27% first present with _____ sx, 1% first present with _____ disease
Clinical Manifestations
- Diarrhea that may be associated with _____
- Bowel movements are ____ and in _____ volumes
- May also have ______ abdominal pain, u_____, t______, and in_______
- Pts with mainly distal disease may have ______ with frequent discharge of _____ and ______
- Onset of symptoms is ______ -> progressive over several weeks
- Symptoms may be preceded with a ____-limiting episode of rectal _____ that occurred weeks or months earlier
reoccuring (relapses and remissions)
mostly mild, moderate, severe
- Blood
- frequent, small
- colicky, urgency, tenesmus (defecation equivalent of dry heaves, feeling of needing to defecate but is not productive), incontinence
- constipation, blood and mucus
- gradual
- self-limiting, bleeding
painful diarrhea may have blood, bouts of diarrhea with rebound constipation common in distal disease
Mild UC
< ___ stools per day with or ______ blood, no signs of systemic ______, no signs of a_____, physical exam often _____. Ulcers _____ to rectum or rectosigmoid. ______ rectal bleeding - ___ diarrhea, mild cramping pain, some periods of constipation
4, without, no toxicity, no anemia, PE normal, confined, Intermittent- mild
Mild disease triggers: usually dt stress vs. food
Moderate UC
Involves ____ of the colon, frequent loose ____ stools (__ 4 per day), abdominal tenderness to _____, mild anemia ___ requiring blood transfusion, abdominal pain that is ___ severe, _____ signs of systemic toxicity such as low grade _____, adequate _____ is maintained usually
more of colon, frequent loose bloody (>4 days), palpation, anemia NO transfusions, pain not severe, minimal signs of toxicity, fever, ADEQUATE NUTRITION
Severe UC
_____ colon involvement that may extend to the _____, frequent loose stools (>__ per day), severe cramps, fever > _____, hypotension, tachycardia, anemia, bleeding often necessitates _____, may suffer rapid ____ loss leading to ______ nutritional state
Extensive, cecum, >6 bms, >37.5, transfusion, weight loss, POOR nutritional state
Ulcerative Colitis Acute Complications
(4)
Severe Bleeding
Fulminant Colitis
Toxic Megacolon
Perforation
Severe Bleeding in UC
Bleeding may be severe in up to 10% of patients. Massive ______ occurs in up to 3% of patients with ulcerative colitis at some time in their disease course and may necessitate urgent _______
hemorrhage, colectomy
Fulminant Colitis
=
Patients with ulcerative colitis may develop fulminant colitis with > __ stools per day, continuous _____, abdominal _____, d_____, and acute severe _____ symptoms including f____ and a______. Patients with fulminant colitis are at high risk of developing _____ ______
Getting severe very quickly vs. normal progression
>10 stools per day, bleeding, pain, distension, toxic, fever and anorexia, Toxic megacolon
Toxic Megacolon
______ process extends beyond mucosa to involve the _____ layers of the colon. Toxic megacolon is characterized by colonic diameter > __ cm or cecal diameter > __ cm and the presence of (1)
Inflammatory process, muscle, colonic diameter > 6, cecal diameter >9, systemic toxicity* (fever, loss of appetite, will need surgical intervention immediately)
Ulcers get deep enough to damage the muscle layer of the colon (remem they’re continuous ulcers) that cause dilation of the colon that feeds into a smaller portion of colon -> obstruction -> buildup of absorption of toxic elements and toxictity
Perforation
Perforation of the colon most commonly occurs as a consequence of?
Perforation with _______ has been associated with 50% mortality in pts with Ulcerative colitis.
Toxic Megacolon (IS THE ULTIMATE CONSEQUENCE)
Periotonitis
Chron’s Disease
Common places to see skip lesions (3)
Ileocecal regions =
- Will see ______ of ileum so ulcers can lead to develoment of ___ tissue and _____ -> dangerous and can lead to _____
oral mucosa, perianal, ileocecal region
terminal ileum leading to cecum
- narrowing, scar tissue and strictures, obstruction
Crohn’s Disease
An _______ disorder characterized by _______ inflammation of the GI tract
Can and may affect any or all of the GI tract from ____ to _____ area
- ~80% of pts have (1) involvement, usually the (1), with 1/3 of pts have ____itis exclusively
- ~50% of patients have ______, involvement of both ileum and colon
- ~20% have disease limits to the _____ (with half of those sparing the rectum)
- ~1/3 of pts have _____ disease
- ~5-15% have predominant involvement of the ___ or ______ area (fewer with involvement of esophagus or small bowel)
idiopathic, transmural
mouth to perianal
- small bowel, distal ileum, ileitis
- ileocolotis
- colon
- perianal
- mouth, gastroduodenal
Crohn’s Disease Clinical Manifestations
Clinical manifestations of Crohn disease (CD) are more ____ that those of UC. Pts can have symptoms for many years prior to diagnosis
Hallmarks of CD: F_____, prolonged _____ with abdominal _____, ____ loss, and _____, with or without gross _____
Variable (bc can happen anywhere)
Fatigue, diarrhea w abdominal pain, weight loss, fever, bleeding
Crohn’s Disease Abdominal Pain
- _____ abdominal pain is a common manifestation of CD, regardless of disease distrubution
- The transmural nature of the inflammatory process results in fibrotic ______. These strictures often lead to repeated episodes of small bowel, or less comonly colonic, ______. A pt with disease limited to the ____ ____ frequently presents with __ ___ ___ pain.
- Occasionally, pts will have no clinical manifestations of CD until luminal narrowing causes _____ and early signs of _____ with abdominal ____.
- Crampy
- strictures, obstruction, distal ileum, RLQ
- constipation, obstruction, pain
Diarrhea in Crohn’s Disease
Diarrhea is a ______ presentation, but often _____ over a long period of time
Diarrhea associated with CD may have multiple causes, including
- Excessive fluid _____ and impaired fluid _____ by inflamed small or large bowel
- ___ ____ malabsorption due to inflamed or resected terminal ileum
- _______ related to loss of bile salts
common, fluctuates
- fluid secretion, impaired fluid absorption
- Bile salt malabsorption
- Steatorrhea
bc bile salts usually reabsorbed at terminal ileum, so ileal disease can result with more bile in colon and osmotic diarrhea
Bleeding in Crohn’s Disease
Although stools frequently reveal the presence of _____ levels of blood (eg + ____ or immunochemical test), gross bleeding is ___ frequent than in UC
An exception to this are some pts with Crohn’s _____
microscopic, +guaic, gross bleeding less frequent
Colitis
Crohn’s Disease Clinical Manifestations
(1) bc you have greater chance of small intestine involvement, being able to absorb enough for adequate nutritional state is more risky
(1) Perianal pain and drainage from large skin tags, anal fissures, perirectal abscesses, and anorectal fistulas
(1) Fatigue is common. Weight loss due to obstruction induced loss of appetite or malabsorption. Feveres caused by chronic inflammation or perforation/peribowel infection.
Malabsorption
Perinanal disease (very painful bc lots of sensory fibers there)
Systemic Symptoms
Crohn’s Manifestations
Fistulas
- ____ or communications that connect two epithelial lined _____.
- Common sites include in____ and bl____, s____, b____, and v_____.
- (1) fistulas: two adjacent loops of intestine can be asymptomatic or just a palpable mass
- (1) fistulas: loop of intestine forms fistula w bladder -> feces enters bladder -> recurrent UTIs
- (1) fistulas: loop of intestine forms fistula w vaginal canal, passage of gas or feces from vagina
- (1) fistulas: can cause bowel contents to drain to surface of the skin
- Tract, organs
- intestine and bladder, skin, bowel, and vagina
- Enteroenteric
- Enterovesical
- Enterovaginal
- Enterocutaneous
like the toxic megacolon of UC - serious consequence
Diverticulosis
=
- Risk factors: diet low in _____ and high in ____ foods, ___ (bc motility of colon goes down bc gets more narrow and muscle layer gets weaker), more susceptible to _____, _____ builds up and tiny weaknesses in colon mucosa herniate)
- General advice = avoid eating foods with _____, small ____
- So generally in ppl > __ and in ______ nations dt access to refined foods
Tiny herniations of colonic mucosa through colon wall (little pouches comint out of the colon) - the pouches itself, largely asymptomatic
- low in fiber, high in refined foods, age, constipation, pressure
- avoid eating foods with seeds and small nuts so as to not get stuck in the pouches
- >60 and industrialized nations dt access to refined foods
Diverticular Disease
=
- Is a relatively common disease that is ___ dependent
- Caused by increased intracolonic _____ brought about by age (_____ of colon with age) and a diet ___ in fiber and ____ in refined foods
- Excessive intra-colon pressure causes _____ of the colonic mucosa at _____ points along the colon wall
- Usually _____ unless diverticuli become inflamed, infected, or ______
- Primary symptom of perforation =
Inflammation of these pouches that can even perforate
- age
- pressure (narrowing), low in fiber, high in refined foods
- pressure, weak
- asymptomatic, unless perforation
- Abdominal pain
Chart of Pathophysiology of Diverticular Disease
