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What is the term for Vomiting of Blood?
What is the term for Passage of Gross Blood through the rectum?
What is the term for Passage of Black Tarry Stool?
Melena (100-200 mL of Blood in the Upper GI can produce this case)
This particular GI issue is usually tested for and not easily visible.
- Occult chronic bleeding from the GI Tract
- *Tests include: Dectection of Blood in Feces (typically patients >= 60 yrs); Iron Deficiency is also an indication (in cases of sufficent bleeding)
Where is the source of bleeding in cases of GI bleeding?
- Upper GI Sources: esophagus, stomach, mouth
- Lower GI Sources: SI, LI, Rectum
- Sign / Symptoms: Shock, Anemia, change if pulse / BP
The GI mucosa is protected by several distinct mechanisms. What are they?
- 1. Mechanical production of mucus and HCO3- (barrier against acid)
- 2. Epithelial cells remove excess hydrogen ions
- 3. Mucosal blood flow removes excess acid
This form of gastritis can be caused by drugs (i.e. NSAID's, aspirin), alcohol, stress.
- Acute Gastritis
- *the stress is acute
What are risk factors for Acute Stress Gastritis?
- Severe Burns
- CNS Trauma
- Sepsis (whole-body inflammatory state, "blood poisoning")
This form of gastritis can be caused by H. pylori leading gastric ulcersw and gastric adenocarcinoma.
- Chronic Gastritis (primary cause of gastritis, highest concentration found in antrum (stomach)
- *very common chronic infection worldwide; most frequently aquired in childhood
- Found in conditions which are unsanitary (oral-oral / fecal-oral transmission)
What test can you perform to check of H. pylori?
Rapid Urease Test (RUT) - gastric biopsy specimen is dropped in solution, if solution changes color then positive for H. pylori, 90% accurate)
What are the causes of Peptic Ulcer Disease (PUD), in order?
- 1. H. pylori
- 2. Acid hypersecretion
- 3. NSAID's (i.e. aspirin)
- Two Kinds of Ulceration: Gastric, Duodenal
What is the mechanism by which H. pylori casues mucosal injury, in order?
- 1. Ammonia
- 2. Cytotoxins
- 3. Mucolytic enzymes
- 4. Cytokines
What are the Signs / Symptoms of PUD?
- Epigastric pain - relieved by food / antacids
- Burning sensation
- Chronic and Recurrent
- Gastric Ulcers - Pain after eating (~30 mins after)
- Duodenal Ulcers - Pain after eating (~2-3 hours after)
What is happening, physiologically, in the cases of Acute Pancreatitis?
- Due to the obstruction of this site, the juices have no where to go and the pancreas swells (inflammation)
Can be due to Biliary Tract disease, alcoholism (>= 80% of hospital admissions), drugs, pancreatic enzymes eating away at organ
What are Signs / Symptoms of Acute Pancreatitis?
- Elevated WBC count
- Severe Abdominal Pain, which radiates through back
Laboratory testing of Serum amylase (carbs) and lipase (fats) concentrations can give impression on severity of condition
Inflammation of the lining of the stomach and intestines, predominantly manifested by upper GI tract symptoms (anorexia, nausea, vomiting), diarrhea, and abdominal discomfort.
- Gastroenteritis - can be due to bacterial, viral, parasitic
- Can be due to person to person contact (E. coli, Salmonella, Norwalk virus)
- Signs / Symptoms - sudden onset and sometimes dramatic, anorexia, nausea, vomiting, borborygmi, abdominal cramps, diarrhea (with or without blood and mucus)
This virus can cause infections year round. 40% of outbreaks of gastroenteritis is in children and adults.
This virus typically occurs during the winter month (Nov / Dec). Severe cases are hospitalized with serious diarrhea, usually in children under 2 years.
What are the major causes of gastroenteritis, in order?
- 1. Enterotoxins - impair intestinal absorption and can provoke secretion of electrolytes and water
- 2. Penetration of mucosa (due to Shigella, Salmonella, E. coli species)
- 3. Chemical toxins (i.e. poisonous mushrooms, potatoes, seafood)
- 4. Heavy metals (i.e. arsenic, lead, mercury (Hg), cadmium)
- 5. Drugs (i.e. broad spectrum antibiotics altering normal gut flora)
This bacteria can occur when one ingests undercooked beef or unpasteurized milk. Can be transmitted fecal-orally.
- Escherichia Coli (E. coli O157:H7)
- Signs / Symptoms - severe abdominal cramps and watery diarrhea that may become grossly bloody within 24 hours.
This condition is caused by staphylococcal enterotoxin, not by staphylococcus itself. Food handlers with skin infections contaminate food left at room temperature.
- Staphylococcal Food Poisoning
- Sign / Symptoms - severe nausea and vomiting (2-8 hours after eating food containing toxins; attack is brief, often lasting 12 hours)
This virus causes dehydrating diarrhea in young children (3-15 months). Most infectious in the late fall and winter months.
This virus causes approximately 90% of
epidemic nonbacterial outbreaks ofgastroenteritis around the world. Most commonly infects older children and adults. Infection occurs year round.
Acute inflammation of colon caused by C. difficile and antibiotic abuse.
- Antibiotic-Associated Colitis - an alteration of normal colonic flora that allows overgrowth of C. difficile
- *almost any antibiotic can lead to C. difficlie
Fake membrane consisting of fibrin, WBCs and necrotic epithelial cells
This inflammatory bowel disease primarily affects the small intestines but may be found in other parts of the GI tract.
Crohn's Disease / Regional Enteritis
What are the causes of Crohn's Disease, in order?
- 1. Genetic
- 2. Immune response (due to environmental, dietary, or infectious agents)
- 3. Smoking
- *seen in Nothern Europeans, Angelo-Saxons; most common among Jews
An abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect.
A pattern of inflammation in a "tubular" organ like colon or vessels which involves the whole thickness of the tubule wall (obstruction).
Obstruction of small intestines which are in segments ("skip areas")
- Segments of diseased
- 35% Ileitis
- 45% Ileocolitis
- 10% Jejunoileitis
- Signs / Symptoms - Chronic Lower GI issues, chronic diarrhea, abdominal pain
- *If colon alone is affected, it is clinically indistinguishable from that of ulcerative colitis.
A motility disorder involving the entire GI tract, causing recurring upper and lower GI symptoms, including variable degrees of abdominal pain, constipation and / or diarrhea, and abdominal bloating.
- Irritable Bowel Syndrome (IBS) - No pathologic cause can be found. Caused by emotional / stress, diet (high protein, low fiber), drugs, hormones affect GI motility.
- *It is believed that the circular and longitudinal muscles of the small bowel and sigmoid are particularly susceptible to motor abnormalities, but this is only a hypothesis.
What are signs / symptoms of IBS?
- Pain relieved by defecation
- Alternating pattern of constipation and diarrhea
- Abdominal distention
- Mucus in stool
- Sensation of incomplete evacuation after defecation
- *There are two major IBS types - constipation predominant IBS and diarrhea predominant IBS
What is the standardized criteria to test for IBS?
- The Rome Criteria - abdominal pain relieved with defecation and a varying pattern of altered stool frequency of form, bloating, or mucus
- *Any pathologic disorders should be ruled out
Incompetence of the lower esophageal sphincter allows reflux of gastric contents into the esophagus, causing burning pain. Prolonged refulx may lead to chronic esophagitis, and in worst cases, cancer.
Gastroesophageal Refulx Disease (GERD)
The most common malignant tumor in the proximal two-thirds of the esophagus
- Squamous Cell Carcinoma (common in parts of Asia & S. Africa)
- 4-5 times more common in blacks than whites
- Risk factors include alcohol ingestion, smoking, achalasia (incompetent sphincter muscles), human papillomavirus (HPV)
The most common malignant tumor in the distal one-third of the esophagus
- 4 times more common among whites than blacks
- Risk factors include smoking
What are the signs and symptoms of Esophageal Cancer?
- Early stage: asymptomatic
- Dysphagia (trouble swallowing) - progressivly degrades to the point that swallowing saliva is difficult
- Poor Prognosis (5 yr survival < 5%)
This plays a significant role in causing stomach cancer.
- Helicobacter pylori (H. pylori)
- Gastric adenocarcinoma accounts for 95% of malignant tumors of the stomach
What are signs and symptoms of Stomach Cancer?
- Satiety (always feeling full), Obstruction, Bleeding (late stage)
- Diagnosed through endoscopy, then CT
- 11,000 deaths (low) in U.S. annually (7th most common cause of death from cancer)
- Extremly high in Japan and China
- 75% of patients, age > 50 yrs
- Blood tests including CBC should be done to assess anemia
- CEA should be measured before and after surgery
What are the common causes of Stomach Cancer?
- 1. H. pylori
- 2. Autoimmune atrophic gastritis and various genetic factors
- 3. Gastric polyps - precursors to cancer
- 4. Chronic gastritis leading to ulcers
An extremely common form of cancer. Symptoms include blood in stool or change in bowel habits
Screenings for fecal occult blood (FOB) are done (annually after age 50 yrs).
Diagnosis through colonoscopy (instead of sigmoidoscop)
- Colorectal Cancer
- 153,000 cases and 52,000 deaths annually
- New cases on the rise but still not beating Lung Cancer rise
- Age > 40 yr rising and tapering off age 60-70 yrs
- 70% of cases occur in the rectum and sigmoid
- 95% adenocarcinomas
What is the etiology of Colorectal Cancer?
- 1. Transformation of Adenomatous polyps
- 2. Chronic Ulcerative Colitis
- 3. Diet (High Protein / Fat / Refined Carbs, Low Fiber).
- Signs / Symptoms: occult (hidden) bleeding, fatigue and weakness due to severe anemia, alternating constipation and increased stool frequency or diarrhea
The largest and most metabolically complex organ.
Has a remarkable capacity for regeneration in response to injury of this organ.
The liver consists of many microscopic functional units
These make up the bulk of the liver
Hepatocytes (parenchymal (functional part) cells)
What are the important function of hepatocytes?
- 1. Regulation of carbohydrate homeostasis
- 2. Excretion of Bile
- 3. Clotting factors
- 4. Serum Albumin
- 5. Formation of Urea
- 6. Detoxification of Drugs
Increased bilirubin production
Decreased liver uptake / conjugation
Decreased biliary excretion
Are found in what condtion?
What compounds are tested for in cases of liver conditions?
- ALP (alkaline phasphatase - found in liver, bone, placenta) - this compound is detected when there is an impairment of bile formation
- GGT (gamma-glutamyl transpeptidase) - the compound is detected when there is an obstruction of the common ducts
- AST (aspartate transaminase) - indicates liver injury (rises in cases of MI, heart failure, muscle injury, CNS disease)
- ALT (alanine aminotransferase) - found in liver cells indicating liver disease
- Serum Albumin - decreased in chronic liver disease
- Serum Ig - rises in cases of chronic liver disease
- αFP (alpha fetoprotein) - increase indicates primary hepatcellular carcinoma
Excessive accumulation of lipid in hepatocytes. The most common response of the liver to injury. The most common cause of macrovascular type of this condition
- Fatty Liver
- Pathogenesis: triglycerides accumulate in the liver because of increased input through synthesis from FFA (free fatty acids) or decreased export as VLDL from the hepatocytes. Increased triglyceride synthesis may result from increased delivery or availability of FFA or from decreased oxidation of FFA in the liver
- Due to:
- 1. Alcoholism
- 2. Obesity
- 3. Diabetes
- Pathology: Triglycerides accumulate as large droplets displacing nuclei making cells look "fat"
Decrease in the number of RBC's and Hb (hemoglobin) content caused by blood loss, deficient erythropoiesis (RBC production), excessive hemolysis (RBC destruction), or any combination of the above.
What are the diagnostic criteria for anemia?
- Men - RBC < 4.5 million/μL; Hb < 14 g/dL; Hct < 42%
- Women - RBC < 4 million/μL; Hb < 12 g/dL; Hct <37%
What are the signs / symptoms of Acute Posthemorrhagic Anemia (Anemia caused by Blood Loss)?
- Weak and rapid pulse
- Rapid respiration
- *This anemia is normacytic in nature (normal-sized cells)
Deficient or defective heme or globin synthesis produces which type of anemia?
- Iron (Fe) Deficient Anemia (Microcytic type (small-cell RBC population))
- Total normal body Fe - Men - 3.5g; Women - 2.5g
- Signs / Symptoms - pica (ingesting non-foods (dirt, paint)), pagophagia (craving for ice), glossitis (tongue inflammation)
- Diagnosis criteria - absent marrow stores of Fe *Ascorbic Acid helps with Fe absorption
B12 deficiency caused by loss of intrinsic factor secretion
- Pernicious Anemia (Anemia caused by Vitamin B12 Deficiency; Macrocyctic type)
- Normally B12 is complexed with intrinsic factors and absorbed through the ileum
- Signs / Symptoms - splenomegaly, hepatomegaly, GI manifestations, Glossitis, neurologic involvement
- Diagnostic findings - achlorhydria (decreased acid production in stomach
This anemia is similar in manifestations to Pernicious Anemia. What is it? How are the two diagnostically different?
- Folate Deficient Anemia
- B12 has neurologic signs, B9 does not
This type of anemia has a shortened RBC life span (normal is ~120 days). The bone marrow production can no longer compensate for the shortened RBC survival.
- Anemia Caused by Excessive Hemolysis
- Signs / Symptoms - Hemolysis and Erythoropoiesis (due to reticulocytosis (hyperactive bone marrow))
Chronic hemolytic anemia occuring almost exlusively in blacks and characterized by malformed RBC's caused by homozygous inheritance of Hb S (due to amino acid "mistake")
- Sickle Cell Anemia
- The malformed shape caused obstruction in vessels and may cause tissue death due to hypoxia; destruction occurs soon after entering circulation
The most common inherited hemolytic disorder. It results from unbalanced Hb synthesis caused by decreased production of at least one globin polypeptide chain.
Thalassemia (common in Mediterranean, African, SE Asian ancestry)
This cancer takes up space in the bone marrow making "normal" cell production lower.
- Due to
- 1. Epstein-Barr Virus
- 2. T-cell leukemia / lymphoma virus
What is the most common malignancy in children ages 3-5 yrs?
ALL - Acute Lymphoblastic Leukemia
Abnormal, excessive generation of thrombin and fibrin in the circulating blood
- DIC - Disseminated Intravascular Coagulation
- Too slow - excessive clotting may lead to vein thrombosis (DVT)
- Too fast - bleeding