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clinical medicine gastrointestinal liver
clinical medicine gastrointestinal liver
what are some possible disorders of the esophagus?
what is atresia of the esophagus?
esophagus has incompletely developed
-- disconnected, hypertrophied upper segment
-- lower segment connected to trachea
usually at level of tracheal bifurcation
easy surgical fix
what is a hiatal hernia?
protrusion of part of the gut into the throax above the diaphragm
most are asymptomtic but 10% of patients will have reflux esophagitis & heart burn
can be misdiagnosed for an MI
what are sliding hiatal hernias?
traction from scarred or congenitally shortened esophagus pulls the cardia of stomach thru esophageal hiatus
what are rolling (paraesophageal) hernias?
part of gastric fundus protrudes thru a defect (weak muscle) in the esophageal hiatus
may be accentuated by increased intraabdominal pressure.
what is achalasia of the esophagus?
: lack of expansion and contraction
failure of gastroesophageal sphincter to relax so food remains within esophagus prox to gastroesophageal sphinter
what are clinical manifestations of esophageal achalasia?
dysphasia (difficulty swallowing)
what is esophageal diverticula?
Developmental or acquired outpouching of esophagus wall
what causes esophageal diverticula?
1. increased intraluminal pressure occuring on posterior wall (over accum of food)
2. inflammation outside the esophagus w/ fibrosis that creates distortion
what are esophageal varices?
tortuous distended veins beneath the esophageal mucosa
caused by vascular disorder due to hepatic portal HTN (usually related to cirrhosis)
what are the symptoms and problems w/ esophageal varices?
rupture occurs when varices reach size grtr than 5 mm in diameter - causes massive hematemesis
what is reflux esophagitis?
Inflammation of esophagus related to injury due to regurgitation of gastric contents- may be associated with hiatal hernia
what is the clinical presentation of reflux esophagitis?
All present in distal 1/3 of esophagus leading to fibrosis & metaplasia (replacement of squamous by columnar epithelium- Barret esophagus)
what are complications related to reflux esophagitis?
Approx 10% of patients will develop adenocarcinoma
what are some possible stomach disorders?
acute peptic ulceration
chronic peptic ulceration
what are the two types of pyloric stenosis?
what is congenital pyloric stenosis?
Congenital narrowing of pyuloric canal
4:1 predominant for males
most common indication for abdominal surgery in 1st 6 months of life.
what causes congenital pyloric stenosis?
hypertrophy of pyloric circular muscle that may be palpated as a mass in the newborn having projectile vomiting
what is acquired pyloric stenosis?
post-inflammation scarring that may lead to pyloric obstruction
ulcer -> inflammation->scarring.
what is gastritis?
an inflammatory disease of the gut
-- acute (erosive)
-- chronic (non-erosive)
what is acute gastritis?
inflammation of gut
mucosal erosions by
-- CNS trauma
-- hypersecretion of gastric acid
what are the symptoms of acute gastritis?
range from abdominal discomfort to massive, life-threatening hemorrhages & gastrical perforation
what are the characteristics of chronic gastritis?
chronic inflammatory changes leading eventually to gastric mucosa atrophy & possibly carcinoma
what are the two types of chronic gastritis?
Type A (autoimmue)
Type B (non-immune, more common)
what is type A chronic gastritis?
associated with pernicious anemia (lack of B12- decreased RBCs can’t fully develop & mature)
what is type B chronic gastritis?
: antral gastritis related to duodenal ulcer
: multifocal related to gastric ulcer & carcinoma
what is an acute peptic ulceration?
aka a stress ulcer
extension of acute erosive gastritis where mucosal erosions penetrate the muscle mucosa
appear 24hrs after severe trauma (acid concentration does NOT inc)
cause bleeding & do not progress to chronic ulcers
what is the progression of acute peptic ulceration?
Start in proximal part but multiple ulcers may involve whole stomach.
Appear within 24 hours after severe trauma, acute brain damage, severe medical illness, surgery, steroid therapy & aspirin abuse
what is the pathogenesis of acute peptic ulceration?
uncertain since acid concentration is not increased
what are chronic peptic ulcers?
result from acid-pepsin digestion of mucosa as solitary lesions
bacteria is the main cause
can treat w/ antibiotics
affects 5-10% of mid adult population
what are the two types of chronic peptic ulcers?
what causes duodenal ulcers?
(a type of chronic peptic ulcer)
genetic predisposition (men, type O blood) who smoke & drink,
high acid secretion
patients with gastric ulcer
what causes gastric ulcers?
(a type of chronic peptic ulcer)
more related to alteration of gastric mucosal resistance than to increased acid secretion & usually is extension of chronic gastritis
what are possible intestinal disorders?
what are hemorrhoids?
variocose veins at the bottom of the colon
associated w/chronic constipation, portal HTN & pregnancy
can be internal (beneath rectal mucosa) or external (beneath anal mucosa)
unusual for those under 30y.o. (except if preg)
what are the symptoms of hemorrhoids?
pain, itching, and rectal bleeding but often not symmptomatic
what is an acute appendicitis?
Inflammatory disease initiated by obstruction of mucous drainage leading to distension, infection, neutrophil emigration, fibrinopurulent exudation, suppurative & gangrenous necrosis
how does an acute appendicitis present clinically?
abdominal discomfort in right lower quadrant, nausea, vomiting
requires immediate surgery upon rupture
what are the complications associated w/ an acute appendicitis?
what is ulcerative colitis?
Acute or chronic inflammation of unknown etiology (possibly infections or autoimmunity) causing extensive ulcerations of the mucosal surface of colon
what is the progression of ulcerative colitis?
begins as mucosal hemorrhages, abscesses & ulcerations in the rectum that spreads proximally & extend to muscular layer
what are the symptoms of ulcerative colitis?
a recurrent disease manifested in adulthood as abdominal pain, cramps & bloody diarrhea
: chron's disease
not much in way of tx
what are common disorders of the liver?
hepatitis A, B, C, D
what is hepatitis?
a viral liver inflammatory disease
may occur as an inapparent infection or a varying disorder from mild and brief to prolonged, severe, necrotic
can be acute or chronic
no cure, but can support liver throughout life
what is Hepatitis A?
RNA virus liver infection acquired by ingestion of fecally-contaminated food & water
damage can be confirmed by rise in serum aminotransferase activity
what is the progression and symptoms of hepatitis A?
incubation period of 2-6 wks
patients develop nonspecific symptoms like fever, malaise, & liver damage
jaundice appears 5-10 days later.
never progresses to chronic hepatitis & infection provides lifelong immunity.
what is Hepatitis B?
DNA virus-acute & chronic liver condition- may be asymptomatic or exceedingly fulminant
virus is transmitted by blood products or contaminated
what is the progression of Hepatitis B?
incubation period of up to 6 months.
((Rest lying down, so BFthru liver increases by ~40%))
what are the different types of Hepatitis B?
: symptoms appear 2-3 months after exposure. Complete recovery & lifelong immunity.
: massive liver necrosis, failure & death
Chronic carrier state
: patients do not develop antigens, infection persists
what is Hepatitis C?
RNA virus- acute or chronic liver infection.
Clinical symptoms similar to Hepatitis B.
Result of transfusion of contaminated blood but may be spread by fecal-oral route.
Can live a normal life if this stays dormant, if not, person will need liver transplant
what is Hepatitis D?
RNA delta (defective) virus
Liver infection that requires help from coexisting Hep B virus infection.
Clinical cause similar to Hep B along w/ Hep C exposure
what is liver cirrhosis?
necrosis, fibrosis and disruption of normal liver architecture
: Laennec's (alcholic) cirrhosis & Postnecrotic (macronodular) cirrhosis
what is Laennec's (alcoholic) cirrhosis?
Common type in U.S.
Causes decreases in liver size with fine nodularity
: liver develops fibrotic consistency & dark color.
what is the progression and symptoms of Laennec's cirrhosis?
Cirrhosis may develop over decades w/symptoms of weight loss, nausea, vomiting, jaundice.
what are complications associated w/ Laennec's cirrhosis?
Patients may develop ascites, esophageal varices, gastritis, & death usually occurs with hepatic failure.
what is postnecrotic (macronodular) cirrhosis?
not related to alcohol abuse
10-30% of total cases of cirrhosis.
May follow a single episode of viral hepatitis or chronic hepatitis, or drug-related hepatotoxicity which results in a marked degree of acute necrosis.
most frequently associated w/liver carcinoma.
what is the progression of postnecrotic cirrhosis?
When symptoms occur, they are often the result of liver failure or portal HTN.
what is the most frequently seen complication of cirrhosis?
results in a backup of blood increasing pressure in the portal vein which can lead to
-- esophageal varices
what is a common disorder of the gallbladder and biliary tract?
more often seen in women, increase in incidence w/age, & are related to obesity & high caloric diets
what is the composition of gallstones?
: most common, w/size from small up to 6 cm in diameter & egg-shell, movement of bile to liver not possible, bile backs bilirubin & blood back up
: less common, related to excessive production of bilirubin, 80% of all biliary calculi.
: rare, mixed stones account for 80% of all biliary calculi.
what is obesity?
an accumulation of body fat above a particular standard
(If standard is 20% above the mean adiposity, then 20% of middle-aged man and 40% woman are obese in US.)
what causes obesity?
possible genetic disposition
excessive calorie intake > calorie expenditure
what are complications related to obesity?
increases the risk of
- type II diabetes
- varicose veins
what is the definition of malnutrition?
20% below normal body weight, (if falls 40% it is marasmus).
loss of fat w/ catabolism of tissue proteins
: thinning of the skin, dec muscle mass and dec serum proteins
(if protein deprivation is greater than calorie reduction like in carbohydrate diet it is kwashiorkor)