21 - Gi

This document discusses diseases of the gastrointestinal tract. It notes that the GI tract is open to the environment and populated by bacteria, and breach of barriers can cause disease. Bleeding, obstruction, and ileus are common problems. Specific conditions discussed include achalasia, hiatal hernia, esophageal varices associated with cirrhosis, reflux esophagitis, and Barrett's esophagus.

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21 - Gi

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DISEASES OF THE GI

TRACT
PART I
MAJOR DETERMINANTS OF DISEASE
• The GI tract is open to the environment.
• The GI tract is populated by billions of bacteria.
• Breach of intestinal barriers is a common cause of disease.
• Mechanical malfunction is a common problem.
• The GI tract is richly vascular and subject to hemorrhage.
• The colon is host to more neoplasms than any other organ in
the body.
• Almost all carcinomas of the colon arise from long-
preexisting benign polyps.
BLEEDING

• RAPID INTESTINAL BLEEDING CAN BE FATAL AND IS CHARACTERIZED

BY WEAKNESS, FAINTING, AND SHOCK.
• INTESTINAL MALIGNANCY IS OFTEN THE CAUSE OF SLOW INTESTINAL
BLEEDING, WHICH IS OFTEN CLINICALLY SILENT AND IF PERSISTENT
CAN CAUSE IRON DEFICIENCY ANEMIA.
BLEEDING

• VOMITED RED BLOOD IS USUALLY FROM THE ESOPHAGUS.

• BLOOD FROM THE STOMACH IS USUALLY ALTERED BY GASTRIC ACID INTO
GRANULAR, BLACK MATERIAL THAT IS ACCURATELY DESCRIBED AS “COFFEE
GROUNDS.”

• THE ORIGIN OF HEMATEMESIS ALMOST INVARIABLY IS BLEEDING FROM

THE ESOPHAGUS, STOMACH, OR DUODENUM.
• BLOOD FROM SITES BELOW THE STOMACH USUALLY APPEARS IN STOOL.
BLEEDING

• UNALTERED RED BLOOD MIXED WITH STOOL IS HEMATOCHEZIA AND USUALLY

ORIGINATES FROM LESIONS IN THE LOWER COLON OR RECTUM.

• BLOOD FROM BLEEDING HEMORRHOIDS OR ANAL FISSURES IS USUALLY BRIGHT

RED AND APPEARS ON, NOT IN, STOOL.

• MELENA IS THE PASSING OF BLACK (TARRY) STOOLS CONTAINING BLOOD ALTERED

BY INTESTINAL AND BACTERIAL DIGESTION.

• MELENA MAY BE CAUSED BY BLEEDING FROM ANY INTESTINAL SITE, INCLUDING

THE ESOPHAGUS.
BLEEDING

• GASTROINTESTINAL BLEEDING MAY BE CAUSED BY TUMORS, ULCERS,

INFLAMMATION, ESOPHAGEAL VARICES, VASCULAR MALFORMATIONS, OR ANY
ONE OF DOZENS OF OTHER CONDITIONS.
• OCCULT BLEEDING IS CLINICALLY UNRECOGNIZED BLEEDING, DETECTED BY
CHEMICAL TESTING OF STOOL.

• GASTROINTESTINAL BLEEDING SHOULD BE CONSIDERED TO ORIGINATE IN AN

INTESTINAL MALIGNANCY UNTIL PROVEN OTHERWISE.
INTESTINAL OBSTRUCTION AND ILEUS

• NORMAL INTESTINAL FUNCTION REQUIRES

CONSTANT PERISTALSIS.
• THIS MAY BE INTERRUPTED BY MECHANICAL
OBSTRUCTION OR BY PERISTALTIC PARALYSIS
(ILEUS).
ILEUS

• THE PATHOGENESIS OF ILEUS IS NOT WELL UNDERSTOOD,

BUT IT CAN BE ASSOCIATED WITH:
• POSTOPERATIVE STATE AFTER ABDOMINAL SURGERY
• APPENDICITIS, GALLBLADDER DISEASE, PERITONITIS, AND
OTHER INTRA-ABDOMINAL INFLAMMATIONS
• INTESTINAL ISCHEMIA
• HYPOKALEMIA
ILEUS

ASSOCIATED WITH: CAUSES:

• VOMITING. • HERNIA.
• PAIN. • ADHESIONS.
• LACK OF BOWEL • INTUSSUSCEPTION.
MOVEMENTS
(OBSTIPATION). • VOLVULUS.

• LACK OF ABDOMINAL
BOWEL SOUNDS.
ILEUS
ILEUS
ESOPHAGUS

• ACHALASIA IS SPASM OF THE ESOPHAGEAL SPHINCTER.

• IT IS TYPICALLY CHRONIC AND INTERMITTENT, AND IT CAUSES PARTIAL
OBSTRUCTION IN THE LOWER ESOPHAGUS NEAR THE ESOPHAGEAL
HIATUS.
• IT PRODUCES DYSPHAGIA AND ESOPHAGEAL PAIN THAT CAN MIMIC
ANGINA.
• THE CAUSE IS UNKNOWN.
ESOPHAGUS

• HIATAL HERNIA IS A PROTRUSION OF PART OF THE STOMACH UPWARD INTO

THE CHEST THROUGH THE DIAPHRAGMATIC OPENING (HIATUS) THAT ALLOWS
PASSAGE OF THE ESOPHAGUS.
• MOST OF THESE PATIENTS ARE ASYMPTOMATIC

• ABOUT 10% EXPERIENCE DYSPHAGIA, PAIN, OR REFLUX OF GASTRIC ACID INTO

THE LOWER ESOPHAGUS.
ESOPHAGUS

• SEVERE VOMITING, AS IN BULIMIA,

FOR EXAMPLE, MAY CAUSE
ESOPHAGEAL LACERATION
• (ALSO KNOWN AS THE MALLORY-
WEISS SYNDROME).
• LACERATIONS USUALLY OCCUR NEAR
THE GASTROESOPHAGEAL JUNCTION
AND CAN BE ASSOCIATED WITH LIFE-
THREATENING BLEEDING.
ESOPHAGUS

• ESOPHAGEAL VARICES ARE LIKE

HEMORRHOIDS—DILATED VEINS FULL OF
BLOOD.
• ESOPHAGEAL VEINS RARELY BECOME
ENLARGED, BUT WHEN THEY DO IT IS
ALMOST ALWAYS ASSOCIATED WITH
CIRRHOSIS OF THE LIVER.

• PORTAL BLOOD IS OBSTRUCTED.

ESOPHAGUS

• ESOPHAGEAL VEINS ARE AN IMPORTANT BYPASS

ROUTE FOR BLOOD TO GET BACK TO THE HEART IF
THE LIVER IS CIRRHOTIC.
• PATIENTS KNOWN TO HAVE CIRRHOSIS CAN BE
PRESUMED TO HAVE ESOPHAGEAL VARICES, WHICH
ARE ESPECIALLY DANGEROUS BECAUSE THEY
PRODUCE NO SYMPTOMS UNTIL RUPTURE; AND
WHEN THEY RUPTURE, THE BLEEDING CAN BE
HORRIFIC AND REQUIRE EMERGENCY TREATMENT.
• AMONG PATIENTS WITH ADVANCED CIRRHOSIS,
HALF DIE OF RUPTURED VARICES, MANY OF THEM
WITH THE FIRST BLEEDING EPISODE.
ESOPHAGUS

• INFLAMMATION OF THE ESOPHAGUS IS MOST OFTEN THE RESULT OF GASTRIC ACID REFLUXING
UPWARD FROM THE STOMACH: REFLUX ESOPHAGITIS.
• PEOPLE OVER AGE 40 ARE MOST OFTEN AFFECTED, AND THE DOMINANT SYMPTOM IS PAIN.
• COMPLICATIONS INCLUDE BLEEDING AND FIBROUS SCARRING (STRICTURE).
• ABOUT 10% OF PATIENTS WITH REFLUX ESOPHAGITIS DEVELOP BARRETT METAPLASIA (OR
BARRETT ESOPHAGUS), A CHANGE OF LOWER ESOPHAGEAL SQUAMOUS EPITHELIUM INTO
ACID-SECRETING GASTRIC EPITHELIUM.
• BARRETT METAPLASIA IS ASSOCIATED WITH AN APPROXIMATE 40 INCREASED RISK FOR
ESOPHAGEAL CARCINOMA.