Git medicine

Dr Musungu Vincent

1. GIT medicine By Musungu V 29/09/2017 Bachelor of Clinical Medicine 1

2. Introduction Course outline Disorders of the alimentary canal Disorders of the hebatobilliary system Disorders of the pancrease 29/09/2017 Bachelor of Clinical Medicine 2

3. Take full history, examine and investigate To do this you need to appreciate few aspects Anatomic considerations; (GI) tract extends from the mouth to the anus and is composed of several organs with distinct functions The GI tract serves two main functions—assimilating nutrients and eliminating waste. GI function is modified by influences outside of the gut. Unlike other organ systems, the gut is in continuity with the outside environment. protective mechanisms are vigilant against deleterious effects of foods, medications, toxins, and infectious organisms Disorders of Alimentary canal Approach to the pt 29/09/2017 Bachelor of Clinical Medicine 3

4. Classification of GI diseases GI diseases are manifestations of alterations in nutrient assimilation or waste evacuation or in the activities supporting these main functions. Thus classified as Impaired Digestion and Absorption Altered Secretion Altered Gut Transit Immune Dysregulation Impaired Gut Blood Flow Neoplastic Degeneration Disorders Without Obvious Organic Abnormalities Genetic disorders 29/09/2017 Bachelor of Clinical Medicine 4

5. GI symptoms 29/09/2017 Bachelor of Clinical Medicine 5

6. NB: Abd . Pain: Visceral pain generally is midline in location and vague in character, while parietal pain is localized and precisely described. upper GI bleeding presents with melena or hematemesis, whereas lower GI bleeding produces passage of bright red or maroon stools. Chronic slow GI bleeding may present with iron deficiency anemia 29/09/2017 Bachelor of Clinical Medicine 6

7. Evaluation of Pt with GI Disease begins with a careful history and exam Subsequent investigation with a variety of tools designed to test gut structure or function are indicated in selected cases. Some patients exhibit normal findings on diagnostic testing. ( functional bowel disorder.) Tools for patient evaluation in GI disease Laboratory, radiographic, functional tests All above can assist in diagnosis of suspected GI disease 29/09/2017 Bachelor of Clinical Medicine 7

8. Laboratory Iron-deficiency anemia suggests mucosal blood loss, vitamin B12 deficiency results from small-intestinal, gastric, or pancreatic disease All above can result from inadequate oral intake Leukocytosis and increased ESR and CRP are found in inflammatory conditions, leukopenia is seen in viremic illness TFT, cortisol, and calcium levels are obtained to exclude endocrinologic causes of GI symptoms. PDT considered for women with unexplained nausea 29/09/2017 Bachelor of Clinical Medicine 8

9. Luminal contents Luminal contents are examined for diagnostic clues. Stool samples are cultured for bacterial pathogens, and also examined for leukocytes and parasites, or tested for Giardia antigen among other parasites Fecal fat is indicate possible malabsorption . Gastric acid is quantified to rule out Zollinger -Ellison syndrome 29/09/2017 Bachelor of Clinical Medicine 9

10. Endoscopy 29/09/2017 Bachelor of Clinical Medicine 10

11. Diseases of the esophagus Symptoms Heartburn ( pyrosis ), MOST common esophageal symptom, characterized by a discomfort or burning sensation behind the sternum arises from the epigastrium and may radiate toward the neck Regurgitation the effortless return of food or fluid into the pharynx without nausea or retching. Patients report a sour or burning fluid in the throat or mouth that may also contain undigested food particles. Bending, belching, or maneuvers that increase intraabdominal pressure can provoke regurgitation 29/09/2017 Bachelor of Clinical Medicine 11

12. Vomiting is preceded by nausea and accompanied by retching. Rumination is a behavior in which recently swallowed food is regurgitated and then reswallowed repetitively for up to an hour There is linkage between rumination and mental deficiency 29/09/2017 Bachelor of Clinical Medicine 12

13. Chest pain a common esophageal symptom with characteristics similar to cardiac pain, making this distinction difficult Esophageal pain is usually experienced as a pressure type sensation in the mid chest, radiating to the mid back, arms, or jaws The similarity to cardiac pain is likely because the two organs share a nerve plexus and the nerve endings in the esophageal wall have poor discriminative ability among stimuli. Gastroesophageal reflux is the most common cause of esophageal chest pain. 29/09/2017 Bachelor of Clinical Medicine 13

14. Esophageal dysphagia is often described as a feeling of food "sticking" or even lodging in the chest Odynophagia Defined as pain either caused by or worsened by swallowing. When odynophagia occur in GERD, it is likely related to an esophageal ulcer or deep erosion. Globus sensation , aka " globus hystericus ," is the perception of a lump or fullness in the throat that is felt irrespective of swallowing often occurs in the setting of anxiety or obsessive-compulsive disorders Water brash Defined as excessive salivation resulting from a vagal reflex triggered by acidification of the esophageal mucosa. This is not a common symptom. 29/09/2017 Bachelor of Clinical Medicine 14

15. Classification of oesophageal disorders Structural e.g Hiatal hernia, Rings and web, Diverticula, Tumors Congenital e.g Esophageal atresia Esophageal Motality Disorders e.g Achalasia, Diffuse esophageal spasms (Des) Gastroesophageal Reflux Disease (GERD) Eosinophillic esophagitis Infectious esophagitis e.g candida, herpes, CMV Mechanical Trauma and Iatrogenic Injury e.g perforation, Mallory Weiss tear, radiation esophagitis, corrosive esophagitis, pill esophagitis, FB Esophageal Manifestations of Systemic Disease e.g Scleroderma and Collagen Vascular Diseases, Dermatologic Diseases 29/09/2017 Bachelor of Clinical Medicine 15

16. Structural disorders Hiatal hernia herniation of viscera, commonly the stomach, into the mediastinum through the esophageal hiatus of the diaphragm There are two main types of hiatal hernia Sliding hiatus hernia (common 95%) Paraesophaeal hernia (further subdivided) read Rings and Webs A lower esophageal mucosal ring , ( B ring) , is a thin membranous narrowing at the squamocolumnar mucosal junction Its origin is unknown.15% of people asymptomatic If lumen diameter <13 mm, distal rings produce episodic solid food dysphagia ( Schatzki rings) 29/09/2017 Bachelor of Clinical Medicine 16

17. Web-like constrictions higher in the esophagus can be congenital or inflammatory origin. When circumferential, they can cause intermittent dysphagia to solids similar to Schatzki rings (treated with dilatation) The combination of symptomatic proximal esophageal webs and iron-deficiency anemia in middle-aged women constitutes Plummer-Vinson syndrome. 29/09/2017 Bachelor of Clinical Medicine 17

18. Diverticula Categorized by location. most common are: epiphrenic, hypopharyngeal ( Zenker's ), mid esophageal Epiphrenic and Zenker's diverticula are false diverticula involving herniation of the mucosa and submucosa through the muscular layer of the esophagus In Zenker's , the obstruction is a stenotic cricopharyngeus muscle (upper esophageal sphincter) In hypopharyngeal herniation most commonly occurs in an area of natural weakness known as Killian's triangle 29/09/2017 Bachelor of Clinical Medicine 18

19. NB: Killian's dehiscence (also known as Killian's triangle , Laimer triangle , Laimer -Killian triangle, or Laimer-Haeckermann area ) is a triangular area in the wall of the pharynx between the thyropharyngeal and cricopharyngeus of the inferior constrictor of the pharynx. 29/09/2017 Bachelor of Clinical Medicine 19

20. Epiphrenic diverticula are associated with achalasia or a distal esophageal stricture. Mid-esophageal diverticula may be caused by traction from adjacent inflammation (classically tuberculosis) Mid-esophageal and epiphrenic diverticula are usually asymptomatic until they enlarge sufficiently to retain food and cause dysphagia and regurgitation 29/09/2017 Bachelor of Clinical Medicine 20

21. Tumors The typical presentation of oesophageal cancer is of progressive solid food dysphagia and weight loss. Associated symptoms may include odynophagia, iron deficiency, and, with mid- esophageal tumours, hoarseness from left recurrent laryngeal nerve injury. Benign esophageal tumors are uncommon 29/09/2017 Bachelor of Clinical Medicine 21

22. Congenital Anomalies The most common congenital esophageal anomaly is esophageal atresia. Dysphagia can also result from congenital abnormalities that cause extrinsic compression of the esophagus In dysphagia lusoria , the esophagus is compressed by an aberrant right subclavian artery arising from the descending aorta and passing behind the esophagus 29/09/2017 Bachelor of Clinical Medicine 22

23. Oesophageal Motility Disorders Are diseases attributable to esophageal neuromuscular dysfunction commonly associated with dysphagia, chest pain, or heartburn. They are: achalasia, diffuse esophageal spasm (DES), GERD Motility disorders can also be secondary to broader disease processes as is the case with pseudoachalasia , Chagas ' disease, and scleroderma. 29/09/2017 Bachelor of Clinical Medicine 23

24. Achalasia A rare disease caused by loss of ganglion cells within the esophageal myenteric plexus. Long-standing achalasia is characterized by progressive dilatation and sigmoid deformity of the esophagus with hypertrophy of the LES. Clinical manifestations may include dysphagia, regurgitation, chest pain, weight loss. Most patients report solid and liquid food dysphagia. Regurgitation occurs when food, fluid, and secretions are retained in the dilated esophagus 29/09/2017 Bachelor of Clinical Medicine 24

25. Patients with advanced achalasia are at risk for bronchitis, pneumonia, lung abscess from chronic regurgitation and aspiration. Chest pain is common early in the course of achalasia, due to esophageal spasm. Patients describe a squeezing, pressure-like retrosternal pain, sometimes radiating to the neck, arms, jaw, and back. Achalasia is diagnosed by barium swallow x-ray and/or esophageal manometry The barium swallow x-ray appearance is of a dilated esophagus with poor emptying, an air-fluid level, and tapering at the LES giving it a beak-like appearance 29/09/2017 Bachelor of Clinical Medicine 25

26. Tx There is no known way of preventing or reversing achalasia. Therapy is directed at reducing LES pressure so that gravity and esophageal pressurization promote esophageal emptying. Peristalsis rarely, if ever, returns. LES pressure can be reduced by: pharmacological therapy, forceful dilatation, surgical myotomy Botulinum toxin, injected into the LES under endoscopic guidance, inhibits acetylcholine release from nerve endings and improves dysphagia 29/09/2017 Bachelor of Clinical Medicine 26

27. Inadequately treated achalasia, esophageal dilatation predisposes to stasis esophagitis. Prolonged stasis esophagitis explains association between achalasia and esophageal squamous cell cancer. 29/09/2017 Bachelor of Clinical Medicine 27

28. Diffuse Esophageal Spasm (Des) Manifested by episodes of dysphagia and chest pain attributable to abnormal esophageal contractions with normal deglutitive LES relaxation Radiographically , DES has been characterized by tertiary contractions or a "corkscrew esophagus in many instances these abnormalities are actually indicative of achalasia 29/09/2017 Bachelor of Clinical Medicine 28

29. DES 29/09/2017 Bachelor of Clinical Medicine 29

30. Esophageal chest pain closely mimics angina pectoris. Features suggesting esophageal pain include pain that is nonexertional , prolonged, interrupts sleep, is meal-related, is relieved with antacids, and is accompanied by heartburn, dysphagia, or regurgitation. 29/09/2017 Bachelor of Clinical Medicine 30

31. Gastroesophageal Reflux Disease (GERD) Gastroesophageal reflux is the return of the stomach's contents back up into the esophagus. In normal digestion, the lower esophageal sphincter (LES) opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagus. Gastroesophageal reflux occurs when the LES is weak or relaxes inappropriately, allowing the stomach's contents to flow up into the esophagus. 29/09/2017 Bachelor of Clinical Medicine 31

32. Pathophysiology Most pts with GERD have esophagitis. Esophagitis occurs when refluxed gastric acid and pepsin cause necrosis of the esophageal mucosa causing erosions and ulcers. esophagitis results from excessive reflux, often accompanied by impaired clearance of the refluxed gastric juice. 29/09/2017 Bachelor of Clinical Medicine 32

33. Three dominant mechanisms of esophagogastric junction incompetence are recognized transient LES relaxations (a vagovagal reflex in which LES relaxation is elicited by gastric distention), LES hypotension, anatomic distortion of the esophagogastric junction inclusive of hiatus hernia. Transient LES relaxations account for 90% of reflux in normal subjects or GERD patients without hiatus hernia. 29/09/2017 Bachelor of Clinical Medicine 33

34. Factors worsening reflux include abdominal obesity, pregnancy, gastric hypersecretory states, delayed gastric emptying, disruption of esophageal peristalsis, gluttony. After acid reflux, peristalsis returns the refluxed fluid to the stomach and acid clearance is completed by titration of the residual acid by bicarbonate contained in swallowed saliva. 29/09/2017 Bachelor of Clinical Medicine 34

35. two causes of prolonged acid clearance are: impaired peristalsis reduced salivation. Impaired peristaltic emptying can be attributable to disrupted peristalsis or superimposed reflux associated with a hiatal hernia. With superimposed reflux, fluid retained within a sliding hiatal hernia refluxes back into the esophagus during swallow-related LES relaxation. 29/09/2017 Bachelor of Clinical Medicine 35

36. Pepsin, bile, and pancreatic enzymes within gastric secretions can also injure the esophageal epithelium, but their noxious properties are either lessened in an acidic environment or dependent on acidity for activation 29/09/2017 Bachelor of Clinical Medicine 36

37. Symptoms of GERD Heart burn Dysphagia Chest pains Extraesophageal syndromes with an established association to GERD include chronic cough, laryngitis, asthma, dental erosions 29/09/2017 Bachelor of Clinical Medicine 37

38. Ddx (read) Complications Bleeding Stricture Esophageal adenocarcinoma 29/09/2017 Bachelor of Clinical Medicine 38

39. Tx Lifestyle modification these fall into three categories: avoidance of foods that reduce lower esophageal sphincter pressure, making them " refluxogenic " (these commonly include fatty foods, alcohol, spearmint, peppermint, tomato-based foods, possibly coffee and tea); avoidance of acidic foods that are inherently irritating; adoption of behaviors to minimize reflux and/or heartburn. 29/09/2017 Bachelor of Clinical Medicine 39

40. The dominant pharmacologic approach to GERD management is with inhibitors of gastric acid secretion. Pharmacologically reducing the acidity of gastric juice does not prevent reflux, but it ameliorates reflux symptoms and allows esophagitis to heal. Proton pump inhibitors (PPIs) are more efficacious than histamine2 receptor antagonists (H2RAs), No major differences exist among PPIs and only modest gain is achieved by increased dosage. 29/09/2017 Bachelor of Clinical Medicine 40

41. Vitamin B12, calcium, and iron absorption may be compromised and susceptibility to enteric infections, particularly Clostridium difficile colitis increased with treatment using PPIs. Read and make notes on: (assignment 1) Eosinophillic esophagitis Infectious esophagitis Esophageal Manifestations of Systemic Disease 29/09/2017 Bachelor of Clinical Medicine 41

42. Mechanical Trauma and Iatrogenic Injury These include; Esophageal Perforation Mallory-Weiss Tear Radiation Esophagitis Corrosive Esophagitis Pill Esophagitis 29/09/2017 Bachelor of Clinical Medicine 42

43. Esophageal Perforation Most cases of esophageal perforation are from instrumentation of the esophagus or trauma. forceful vomiting or retching can lead to spontaneous rupture at the gastroesophageal junction ( Boerhaave's syndrome) corrosive esophagitis or neoplasms can lead to perforation Esophageal perforation causes pleuritic retrosternal pain that can be associated with pneumomediastinum and subcutaneous emphysema. Mediastinitis is a major complication of esophageal perforation 29/09/2017 Bachelor of Clinical Medicine 43

44. CT of the chest is most sensitive in detecting mediastinal air Treatment includes nasogastric suction and parenteral broad-spectrum antibiotics with prompt surgical drainage and repair in noncontained leaks. Conservative therapy with NPO status and antibiotics without surgery may be appropriate 29/09/2017 Bachelor of Clinical Medicine 44

45. Mallory-Weiss Tear Vomiting, retching, or vigorous coughing can cause a nontransmural tear at the gastroesophageal junction that is a common cause of upper gastrointestinal bleeding. Most patients present with hematemesis. Bleeding usually abates spontaneously, but protracted bleeding may respond to local epinephrine or cauterization therapy, endoscopic clipping, or angiographic embolization. Surgery is rarely needed. 29/09/2017 Bachelor of Clinical Medicine 45

46. Radiation Esophagitis can complicate treatment for thoracic cancers, especially breast and lung, with the risk proportional to radiation dosage. Radiosensitizing drugs such as doxorubicin, bleomycin, cyclophosphamide, and cisplatin also increase the risk. Dysphagia and odynophagia may last weeks to months after therapy Radiation exposure in excess of 5000 cGY has been associated with increased risk of esophageal stricture 29/09/2017 Bachelor of Clinical Medicine 46

47. Corrosive Esophagitis Caustic esophageal injury from ingestion of alkali or, acid can be accidental or from attempted suicide Absence of oral injury does not exclude possible esophageal involvement. early endoscopic evaluation is recommended to assess and grade the injury to the esophageal mucosa Severe corrosive injury may lead to esophageal perforation, bleeding, stricture, and death Healing of more severe grades of caustic injury is commonly associated with severe stricture formation and often requires repeated dilatation. 29/09/2017 Bachelor of Clinical Medicine 47

48. Pill Esophagitis occurs when a swallowed pill fails to traverses the entire esophagus and lodges within the lumen attributed to poor "pill taking habits": inadequate liquid with the pill, or lying down immediately after taking a pill The most common location for the pill to lodge is in the mid-esophagus near the crossing of the aorta or carina Typical symptoms of pill esophagitis are the sudden onset of chest pain and odynophagia 29/09/2017 Bachelor of Clinical Medicine 48

49. Peptic Ulcer Disease An ulcer is defined as disruption of the mucosal integrity of the stomach and/or duodenum leading to a local defect or excavation due to active inflammation Ulcers occur within the stomach and/or duodenum and are often chronic in nature 29/09/2017 Bachelor of Clinical Medicine 49

50. Pathophysiologic Basis of Peptic Ulcer Disease PUD encompasses both gastric and duodenal ulcers. Ulcers are defined as breaks in the mucosal surface >5 mm in size, with depth to the submucosa. Duodenal ulcers (DUs) and gastric ulcers (GUs); share many common features in terms of pathogenesis, diagnosis, and treatment, but several factors distinguish them from one another. 29/09/2017 Bachelor of Clinical Medicine 50

51. Epidemiology DU The death rates, need for surgery, and physician visits have decreased by >50% over the past 30 years. The reason for the reduction in the frequency of DUs is due to decreasing frequency of Helicobacter pylori. Before the discovery of H. pylori, the natural history of DUs was typified by frequent recurrences after initial therapy. Eradication of H. pylori has greatly reduced these recurrence rates. 29/09/2017 Bachelor of Clinical Medicine 51

52. Gastric Ulcers occur later in life than duodenal lesions, with a peak incidence reported in the sixth decade. >50% of GUs occur in males less common than DUs, due to the higher likelihood of GUs being silent and presenting only after a complication develops. similar incidence of DUs and GUs. 29/09/2017 Bachelor of Clinical Medicine 52

53. Pathology Duodenal Ulcers DUs occur most often in the first portion of the duodenum (>95%), ~90% located within 3 cm of the pylorus. are usually 1 cm in diameter but can occasionally reach 3–6 cm (giant ulcer). Ulcers are sharply demarcated, with depth at times reaching the muscularis propria . The base of the ulcer often consists of a zone of eosinophilic necrosis with surrounding fibrosis. Malignant DUs are extremely rare. 29/09/2017 Bachelor of Clinical Medicine 53

54. Gastric Ulcers In contrast to DUs, GUs can represent a malignancy and should be biopsied upon discovery. Benign GUs are most often found distal to the junction between the antrum and the acid secretory mucosa. Benign GUs are quite rare in the gastric fundus are histologically similar to DUs. Benign GUs associated with H. pylori are also associated with antral gastritis. 29/09/2017 Bachelor of Clinical Medicine 54

55. In contrast, NSAID-related GUs are not accompanied by chronic active gastritis may have evidence of a chemical gastropathy , typified by foveolar hyperplasia , edema of the lamina propria , and epithelial regeneration in the absence of H. pylori. 29/09/2017 Bachelor of Clinical Medicine 55

56. Pathophysiology Duodenal Ulcers H. pylori and NSAID-induced injury account for the majority of DUs. average basal and nocturnal gastric acid secretion appears to be increased in DU patients Gastric Ulcers As in DUs, the majority of GUs can be attributed to either H. pylori or NSAID-induced mucosal damage. GUs that occur in the prepyloric area or those in the body associated with a DU or a duodenal scar are similar in pathogenesis to DUs. 29/09/2017 Bachelor of Clinical Medicine 56

57. H. Pylori and Acid Peptic Disorders Gastric infection with the bacterium H. pylori accounts for the majority of PUD . plays a role in the development of gastric mucosa-associated lymphoid tissue (MALT) lymphoma and gastric adenocarcinoma. it is still not clear how H pylori, causes ulceration in the duodenum, or whether its eradication will lead to a decrease in gastric cancer. 29/09/2017 Bachelor of Clinical Medicine 57

58. NSAID-Induced Disease Prostaglandins play a critical role in maintaining gastroduodenal mucosal integrity and repair. interruption of prostaglandin synthesis can impair mucosal defense and repair, thus facilitating mucosal injury via a systemic mechanism. to the gastric microcirculation plays an essential role in the initiation of NSAID-induced mucosal injury. 29/09/2017 Bachelor of Clinical Medicine 58

59. Injury to the mucosa also occurs as a result of the topical encounter with NSAIDs The interplay between H. pylori and NSAIDs in the pathogenesis of PUD is complex each of these aggressive factors is independent and synergistic risk factors for PUD and its complications such as GI bleeding. eradication of H. pylori reduces the likelihood of GI complications. 29/09/2017 Bachelor of Clinical Medicine 59

60. Clinical features Abdominal pain is common to many GI disorders, including DU and GU; Epigastric pain described as a burning or gnawing discomfort can be present in both DU and GU Up to 10% of patients with NSAID-induced mucosal disease can present with a complication (bleeding, perforation, and obstruction) without antecedent symptoms . The typical pain pattern in DU occurs 90 minutes to 3 hours after a meal and is frequently relieved by antacids or food 29/09/2017 Bachelor of Clinical Medicine 60

61. Pain that awakes the patient from sleep (between midnight and 3 A.M.) is the most discriminating symptom, is 66% due to DU Nausea and weight loss occur more commonly in GU patients. Endoscopy detects ulcers in <30% of patients who have dyspepsia . 29/09/2017 Bachelor of Clinical Medicine 61

62. Physical Examination Epigastric tenderness is the most frequent finding in patients with GU or DU. Pain may be found to the right of the midline in 20% of patients Tachycardia and orthostasis suggest dehydration secondary to vomiting or active GI blood loss. A severely tender, board like abdomen suggests a perforation. Presence of a succussion splash indicates retained fluid in the stomach, suggesting gastric outlet obstruction. 29/09/2017 Bachelor of Clinical Medicine 62

63. PUD-Related Complications Gastrointestinal Bleeding Perforation Gastric Outlet Obstruction 29/09/2017 Bachelor of Clinical Medicine 63

64. Diagnostic Evaluation of PUD Documentation of an ulcer requires either a radiographic (barium study) or an endoscopic procedure. However , a large percentage of patients with symptoms suggestive of an ulcer have NUD; empirical therapy is appropriate for individuals who are otherwise healthy and <45 years of age, before embarking on a diagnostic evaluation 29/09/2017 Bachelor of Clinical Medicine 64

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67. Therapy of H. Pylori 29/09/2017 Bachelor of Clinical Medicine 67

68. Failure of H. pylori eradication with triple therapy in a compliant patient is usually due to infection with a resistant organism. Quadruple therapy, where clarithromycin is substituted for metronidazole (or vice versa), should be the next step The combination of pantoprazole, amoxicillin, and rifabutin for 10 days has also been used successfully (86% cure rate) in patients infected with resistant strains 29/09/2017 Bachelor of Clinical Medicine 68

69. Additional regimens considered for second-line therapy include levofloxacin-based triple therapy (levofloxacin, amoxicillin, PPI) for 10 days furazolidone -based triple therapy ( furazolidone , amoxicillin, PPI) for 14 days 29/09/2017 Bachelor of Clinical Medicine 69

70. Therapy of NSAID-Related Gastric or Duodenal Injury 29/09/2017 Bachelor of Clinical Medicine 70

71. Approach and Therapy if a patient <50 years of age present with dyspepsia and without alarming signs or symptoms suggestive of an ulcer complication or malignancy, an empirical therapeutic trial with acid suppression is recommended Once an ulcer (GU or DU) is documented, the main issue at stake is whether H. pylori or an NSAID is involved. With H. pylori present, independent of the NSAID status, triple therapy is recommended for 14 days, followed by continued acid-suppressing drugs (H 2 receptor antagonist or PPIs) for a total of 4–6 weeks 29/09/2017 Bachelor of Clinical Medicine 71

72. A GU that fails to heal after 12 weeks and a DU that does not heal after 8 weeks of therapy should be considered refractory. In relation to PUD Read Surgical management of PUD (Indications and precautions) Afferent loop syndrome Dumping syndrome 29/09/2017 Bachelor of Clinical Medicine 72

73. Zollinger Ellison Syndrome (ZES) Severe peptic ulcer diathesis secondary to gastric acid hypersecretion due to unregulated gastrin release from a non- cell endocrine tumor ( gastrinoma ) defines the components of ZES. it can be cured by surgical resection in up to 30% of patients . 29/09/2017 Bachelor of Clinical Medicine 73

74. Epidemiology incidence of ZES varies from 0.1–1% of individuals presenting with PUD. Males are more commonly affected than females, and the majority of patients are diagnosed between ages 30 and 50. Gastrinomas are classified into sporadic tumors (more common) and those associated with multiple endocrine neoplasia (MEN) type I 29/09/2017 Bachelor of Clinical Medicine 74

75. A vailability and use of PPIs has led to a decreased patient referral for gastrinoma evaluation, delay in diagnosis , and an increase in false-positive diagnoses of ZES . 29/09/2017 Bachelor of Clinical Medicine 75

76. Pathophysiology Hypergastrinemia originating from an autonomous neoplasm is the driving force responsible for the clinical manifestations in ZES. Gastrin stimulates acid secretion through gastrin receptors on parietal cells and by inducing histamine release from ECL cells . Gastrin also has a trophic action on gastric epithelial cells. 29/09/2017 Bachelor of Clinical Medicine 76

77. Long-standing hypergastrinemia leads to markedly increased gastric acid secretion through both parietal cell stimulation and increased parietal cell mass. The increased gastric acid output leads to peptic ulcer diathesis, erosive esophagitis, and diarrhea . 29/09/2017 Bachelor of Clinical Medicine 77

78. CFs Gastric acid hypersecretion is responsible for S&S Peptic ulcer is the most common clinical manifestation, occurring in >90% of gastrinoma patients. Initial presentation and ulcer location (duodenal bulb) may be indistinguishable from common PUD. 29/09/2017 Bachelor of Clinical Medicine 78

79. Clinical situations that should create suspicion of gastrinoma : ulcers in unusual locations (second part of the duodenum and beyond) , ulcers refractory to standard medical therapy, ulcer recurrence after acid-reducing surgery, ulcers presenting with frank complications (bleeding, obstruction, and perforation) , ulcers in the absence of H. pylori or NSAID ingestion . 29/09/2017 Bachelor of Clinical Medicine 79

80. Diarrhea, common clinical manifestation in ZES, is found in up to 50% of patients 29/09/2017 Bachelor of Clinical Medicine 80

81. Diarrhea in ZES, WHY? Etiology of the diarrhea is multifactorial, resulting from marked volume overload to the small bowel, pancreatic enzyme inactivation by acid, damage of the intestinal epithelial surface by acid. The epithelial damage can lead to a mild degree of maldigestion and malabsorption of nutrients. 29/09/2017 Bachelor of Clinical Medicine 81

82. The diarrhea may also have a secretory component This is due to the direct stimulatory effect of gastrin on enterocytes the co-secretion of additional hormones from the tumor e.g vasoactive intestinal peptide (VIP) 29/09/2017 Bachelor of Clinical Medicine 82

83. Dx of ZES The first step in the evaluation of a patient suspected of having ZES is to obtain a fasting gastrin level. Fasting gastrin levels are usually <150 pg /mL all gastrinoma patients will have a gastrin level >150–200 pg / mL. Measurement of fasting gastrin should be repeated to confirm the clinical suspicion. 29/09/2017 Bachelor of Clinical Medicine 83

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85. Causes of elevated fasting Gastrin levels gastric hypochlorhydria or achlorhydria (the most frequent), with or without pernicious anemia ; retained gastric antrum; G cell hyperplasia; gastric outlet obstruction; renal insufficiency; massive small-bowel obstruction; Others conditions e.g rheumatoid arthritis, vitiligo, diabetes mellitus, and pheochromocytoma . in patients using antisecretory agents for the treatment of acid peptic disorders and dyspepsia 29/09/2017 Bachelor of Clinical Medicine 85

86. Point to NOTE F asting gastrin >10 times normal is highly suggestive of ZES, two-thirds of patients will have fasting gastrin levels that overlap with levels found in the more common disorders outlined above . A BAO/MAO ratio >0.6 is highly suggestive of ZES If the technology for measuring gastric acid secretion is not available, a basal gastric pH 3 virtually excludes a gastrinoma . 29/09/2017 Bachelor of Clinical Medicine 86

87. Once the biochemical diagnosis of gastrinoma has been confirmed, the tumor must be located (Using CT scan, ultra sound, MRI) 29/09/2017 Bachelor of Clinical Medicine 87

88. Tx of ZES AIMS ameliorating the signs and symptoms related to hormone overproduction, curative resection of the neoplasm, control tumor growth in metastatic disease. 29/09/2017 Bachelor of Clinical Medicine 88

89. PPIs are the treatment of choice and have decreased the need for total gastrectomy. Initial PPI doses tend to be higher than those used for treatment of GERD or PUD. The initial dose of omeprazole, lansoprazole, rabeprazole or esomeprazole should be in the range of 60 mg in divided doses in a 24-hour period Surgery (Definitive tx ) 29/09/2017 Bachelor of Clinical Medicine 89

90. Stress related mucosal injury Patients suffering from shock, sepsis, massive burns, severe trauma, or head injury can develop acute erosive gastric mucosal changes or frank ulceration with bleeding. Classified as stress-induced gastritis or ulcers, injury is most commonly observed in the acid-producing (fundus and body) portions of the stomach . 29/09/2017 Bachelor of Clinical Medicine 90

91. elevated gastric acid secretion may be noted in patients with stress ulceration after head trauma (Cushing's ulcer) Gastric secretion can also be noted in severe burns (Curling's ulcer), M ucosal ischemia and breakdown of the normal protective barriers of the stomach also play an important role in the pathogenesis. 29/09/2017 Bachelor of Clinical Medicine 91

92. Gastritis The term gastritis should be reserved for histologically documented inflammation of the gastric mucosa. Gastritis is not the mucosal erythema seen during endoscopy and is not interchangeable with "dyspepsia." The correlation between the histologic findings of gastritis, the clinical picture of abdominal pain or dyspepsia, and endoscopic findings noted on gross inspection of the gastric mucosa is poor. Therefore , there is no typical clinical manifestation of gastritis. 29/09/2017 Bachelor of Clinical Medicine 92

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94. Acute Gastritis most common causes of acute gastritis are infectious. Acute infection with H. pylori induces gastritis present with sudden onset of epigastric pain, nausea , vomiting , limited mucosal histologic studies demonstrate a marked infiltrate of neutrophils with edema and hyperemia. If not treated, this picture will evolve into chronic gastritis. Hypochlorhydria lasting for up to 1 year may follow acute H. pylori infection. 29/09/2017 Bachelor of Clinical Medicine 94

95. Bacterial infection of the stomach or phlegmonous gastritis is a rare, potentially life-threatening disorder characterized by marked and diffuse acute inflammatory infiltrates of the entire gastric wall, xterised by necrosis. Elderly individuals, alcoholics, and AIDS patients may be affected by phlegmonous gastritis 29/09/2017 Bachelor of Clinical Medicine 95

96. Chronic Gastritis identified histologically by an inflammatory cell infiltrate consisting primarily of lymphocytes and plasma cells, with very scant neutrophil involvement Chronic gastritis has been classified according to histologic characteristics. These include superficial atrophic changes gastric atrophy . 29/09/2017 Bachelor of Clinical Medicine 96

97. Stages of chronic gastritis The early phase of chronic gastritis is superficial gastritis inflammatory changes are limited to the lamina propria of the surface mucosa, with edema and cellular infiltrates separating intact gastric glands The next stage is atrophic gastritis . In this case the inflammatory infiltrate extends deeper into the mucosa, with progressive distortion and destruction of the glands . The final stage of chronic gastritis is gastric atrophy . In this case, glandular structures are lost, and there is inflammatory infiltrates. Endoscopically , the mucosa may be substantially thin, permitting clear visualization of the underlying blood vessels. 29/09/2017 Bachelor of Clinical Medicine 97

98. Chronic gastritis is also classified according to the predominant site of involvement . Type A refers to the body-predominant form (autoimmune) Type B is the antral-predominant form ( H. pylori –related). AB gastritis has been used to refer to a mixed antral/body picture. 29/09/2017 Bachelor of Clinical Medicine 98

99. Tx of chronic gastritis Treatment in chronic gastritis is aimed at the sequelae and not the underlying inflammation. Patients with pernicious anemia will require parenteral vitamin B12 supplementation on a long-term basis. Eradication of H. pylori is not routinely recommended unless PUD or a low-grade MALT lymphoma is present. 29/09/2017 Bachelor of Clinical Medicine 99

100. HOME WORK MéNéTrier's Disease and TX Lymphocytic gastritis 29/09/2017 Bachelor of Clinical Medicine 100

101. Disorders of Absorption Constitute a broad spectrum of conditions with multiple etiologies and varied clinical manifestations. All of these clinical problems are associated with diminished intestinal absorption of one or more dietary nutrients and are often referred to as the malabsorption syndrome . Malabsorption syndromes are associated with steatorrhea which is: an increase in stool fat excretion of >6% of dietary fat intake 29/09/2017 Bachelor of Clinical Medicine 101

102. Disorders of absorption must be included in the differential diagnosis of diarrhea . diarrhea is frequently associated with and/or is a consequence of the diminished absorption of one or more dietary nutrients . Diarrhea as a symptom (i.e., when used by patients to describe their bowel movement pattern) may mean; a decrease in stool consistency, an increase in stool volume, an increase in number of bowel movements, any combination of the above . 29/09/2017 Bachelor of Clinical Medicine 102

103. In contrast , diarrhea as a sign is a quantitative increase in stool water or weight of >200–225 mL or gram per 24 h. 29/09/2017 Bachelor of Clinical Medicine 103

104. Celiac Disease Tropical Sprue Short Bowel Syndrome Whipple's Disease Protein-Losing Enteropathy 29/09/2017 Bachelor of Clinical Medicine 104

105. Celiac Disease Common cause of malabsorption of one or more nutrients. Celiac disease has had several other names, including nontropical sprue, celiac sprue, adult celiac disease, and gluten-sensitive enteropathy . The etiology of celiac disease is not known, but environmental, immunologic, and genetic factors are important . Individuals have manifestations that are not obviously related to intestinal malabsorption, e.g., anemia, osteopenia, infertility, neurologic symptoms 29/09/2017 Bachelor of Clinical Medicine 105

106. The hallmark of celiac disease is the presence of an abnormal small-intestinal biopsy and the response of the condition—symptoms and the histologic changes on the small-intestinal biopsy—to the elimination of gluten from the diet. symptoms of celiac disease may appear with the introduction of cereals in an infant's diet spontaneous remissions often occur during the second decade of life that may be either permanent or followed by the reappearance of symptoms over several years. 29/09/2017 Bachelor of Clinical Medicine 106

107. Symptoms malabsorption of multiple nutrients, diarrhea , steatorrhea , weight loss, the consequences of nutrient depletion (i.e., anemia and metabolic bone disease), absence of any gastrointestinal symptoms but with evidence of the depletion of a single nutrient (e.g., iron or folate deficiency, osteomalacia , edema from protein loss). 29/09/2017 Bachelor of Clinical Medicine 107

108. Etiology The etiology of celiac disease is not known, but environmental, immunologic, and genetic factors contribute to the disease. E nvironmental association of the disease with gliadin, a component of gluten that is present in wheat, barley, and rye immunologic the pathogenesis of celiac disease is critical and involves both adaptive and innate immune responses. Serum antibodies—IgA antigliadin , IgA antiendomysial , and IgA anti- tTG antibodies—are present 29/09/2017 Bachelor of Clinical Medicine 108

109. Genetic factor The incidence of symptomatic celiac disease varies widely in different population groups (high in whites, low in blacks and Asians) and is 10% in first-degree relatives of celiac disease patients 29/09/2017 Bachelor of Clinical Medicine 109

110. Dx A small-intestinal biopsy A biopsy should be performed in patients with symptoms and laboratory findings suggestive of nutrient malabsorption and/or deficiency and with a positive endomysial antibody test Diagnosis of celiac disease requires the presence of characteristic histologic changes on small-intestinal biopsy together with a prompt clinical and histologic response following the institution of a gluten-free diet 29/09/2017 Bachelor of Clinical Medicine 110

111. Failure to respond most common cause of persistent symptoms in a patient who fulfills all the criteria for the diagnosis of celiac disease is continued intake of gluten . Use of rice in place of wheat flour is very helpful several support groups provide important aid to patients with celiac disease and to their families. More than 90% of patients will respond to complete dietary gluten restriction. 29/09/2017 Bachelor of Clinical Medicine 111

112. Mechanism of diarrhea in celiac disease steatorrhea, which is primarily a result of the changes in jejunal mucosal function steatorrhea, which is primarily a result of the changes in jejunal mucosal function bile acid malabsorption resulting in bile acid–induced fluid secretion in the colon , endogenous fluid secretion resulting from crypt hyperplasia 29/09/2017 Bachelor of Clinical Medicine 112

113. most important complication of celiac disease is the development of cancer 29/09/2017 Bachelor of Clinical Medicine 113

114. Tropical Sprue a poorly understood syndrome that affects both expatriates and natives in certain but not all tropical areas is manifested by chronic diarrhea, steatorrhea , weight loss , nutritional deficiencies, including those of both folate and cobalamin. This disease affects 5–10% of the population in some tropical areas. 29/09/2017 Bachelor of Clinical Medicine 114

115. Chronic diarrhea in a tropical environment is caused by infectious agents G . lamblia , Yersinia enterocolitica , C . difficile , Cryptosporidium parvum , Cyclospora cayetanensis 29/09/2017 Bachelor of Clinical Medicine 115

116. dx best made by the presence of an abnormal small-intestinal mucosal biopsy in an individual with chronic diarrhea and evidence of malabsorption who is either residing or has recently lived in a tropical country 29/09/2017 Bachelor of Clinical Medicine 116

117. S mall-intestinal biopsy in tropical sprue does not have pathognomonic features but resembles, and can often be indistinguishable from, that seen in celiac disease 29/09/2017 Bachelor of Clinical Medicine 117

118. tx Broad-spectrum antibiotics and folic acid are most often curative, especially if the patient leaves the tropical area and does not return. Tetracycline should be used for up to 6 months and may be associated with improvement within 1–2 weeks. 29/09/2017 Bachelor of Clinical Medicine 118

119. Folic acid alone will induce a hematologic remission as well as improvement in appetite, weight gain, and some morphologic changes in small intestinal biopsy . Because of the presence of marked folate deficiency, folic acid is most often given together with antibiotics. 29/09/2017 Bachelor of Clinical Medicine 119

120. Short Bowel Syndrome Represents myriad clinical problems that occur following resection of varying lengths of small intestine; may be congenital, e.g., microvillous inclusion disease . 29/09/2017 Bachelor of Clinical Medicine 120

121. Factors that determine symptoms the specific segment (jejunum vs. ileum) resected, the length of the resected segment, the integrity of the ileocecal valve, whether any large intestine has also been removed, residual disease in the remaining small and/or large intestine (e.g., Crohn's disease, mesenteric artery disease ), the degree of adaptation in the remaining intestine 29/09/2017 Bachelor of Clinical Medicine 121

122. Short bowel syndrome can occur at any age from neonates through the elderly. Intestinal failure is the inability to maintain nutrition without parenteral support. 29/09/2017 Bachelor of Clinical Medicine 122

123. Tx Depends on the severity of symptoms Also dependes on whether the individual is able to maintain caloric and electrolyte balance with oral intake alone. Initial treatment includes judicious use of opiates (including codeine) to reduce stool output and to establish an effective diet. An initial diet should be low-fat and high-carbohydrate to minimize the diarrhea from fatty acid stimulation of colonic fluid secretion 29/09/2017 Bachelor of Clinical Medicine 123

124. Bacterial Overgrowth Syndrome comprises a group of disorders with diarrhea , steatorrhea , macrocytic anemia C ommon feature is the proliferation of colonic-type bacteria within the small intestine bacterial proliferation is due to stasis caused by impaired peristalsis ( functional stasis ), changes in intestinal anatomy ( anatomic stasis ), direct communication between the small and large intestine. 29/09/2017 Bachelor of Clinical Medicine 124

125. These conditions have also been referred to as stagnant bowel syndrome or blind loop syndrome . 29/09/2017 Bachelor of Clinical Medicine 125

126. dX The diagnosis may be suspected from the combination of a low serum cobalamin level and an elevated serum folate level, as enteric bacteria frequently produce folate compounds that will be absorbed in the duodenum. 29/09/2017 Bachelor of Clinical Medicine 126

127. tX Surgical correction of an anatomic blind loop For functional stasis of scleroderma or certain anatomic stasis states (e.g., multiple jejunal diverticula) be treated with broad-spectrum antibiotics. Tetracycline challenged with high resistance, other antibiotics such as metronidazole, amoxicillin/clavulanic acid, and cephalosporins have been employed . The antibiotic should be given for approximately 3 weeks or until symptoms remit 29/09/2017 Bachelor of Clinical Medicine 127

128. Whipple's Disease Its a chronic multisystem disease associated with diarrhea, steatorrhea, weight loss, arthralgia, and central nervous system (CNS) and cardiac problems; it is caused by the bacteria Tropheryma whipple 29/09/2017 Bachelor of Clinical Medicine 128

129. Cfs diarrhea , steatorrhea , abdominal pain, weight loss, migratory large-joint arthropathy , fever ophthalmologic and CNS symptoms. 29/09/2017 Bachelor of Clinical Medicine 129

130. Dx History tissue biopsies from the small intestine and/or other organs that may be involved (e.g., liver, lymph nodes, heart, eyes, CNS, or synovial membranes), based on the patient's symptoms, is the primary approach to establish the diagnosis of Whipple's disease. 29/09/2017 Bachelor of Clinical Medicine 130

131. Tx prolonged use of antibiotics. The current drug of choice is double-strength trimethoprim/sulfamethoxazole for approximately 1 year. 29/09/2017 Bachelor of Clinical Medicine 131

132. Read PLE (Protein Loosing enteropathy) Presentation Dx management 29/09/2017 Bachelor of Clinical Medicine 132

133. The Schilling Test Performed to determine the cause for cobalamin malabsorption Cobalamin absorption may be abnormal in the following: Pernicious anemia, Chronic pancreatitis Achlorhydria , . Bacterial overgrowth syndromes, Ileal dysfunction 29/09/2017 Bachelor of Clinical Medicine 133

134. The Schilling test is performed by administering cobalamin orally and collecting urine for 24 h, it is dependent on normal renal and bladder function. Urinary excretion of cobalamin will reflect cobalamin absorption provided that intrahepatic binding sites for cobalamin are fully occupied. 29/09/2017 Bachelor of Clinical Medicine 134

135. The Schilling test may be abnormal (usually defined as <10% excretion in 24 h) in pernicious anemia, chronic pancreatitis, blind loop syndrome, ileal disease 29/09/2017 Bachelor of Clinical Medicine 135

136. Inflammatory Bowel Disease Inflammatory bowel disease (IBD) is an immune-mediated chronic intestinal condition. Types Ulcerative colitis (UC) Crohn's disease (CD ). 29/09/2017 Bachelor of Clinical Medicine 136

137. Ulcerative colitis The major symptoms of UC are: diarrhea , rectal bleeding, tenesmus , passage of mucus, crampy abdominal pain 29/09/2017 Bachelor of Clinical Medicine 137

138. Severity of symptoms correlates with the extent of disease. UC can present acutely, symptoms usually have been present for weeks to months. Occasionally , diarrhea and bleeding are so intermittent and mild that the patient does not seek medical attention. 29/09/2017 Bachelor of Clinical Medicine 138

139. Laboratory, Endoscopic, and Radiographic Features rise in acute-phase reactants [C-reactive protein (CRP)], platelet count, erythrocyte sedimentation rate (ESR), a decrease in hemoglobin . Fecal lactoferrin is a highly sensitive and specific marker for detecting intestinal inflammation . Fecal calprotectin levels correlate well with histologic inflammation, predict relapses, and detect pouchitis 29/09/2017 Bachelor of Clinical Medicine 139

140. Sigmoidoscopy is used to assess disease activity and is usually performed before treatment The earliest radiologic change of UC seen on single-contrast barium enema is a fine mucosal granularity. With increasing severity, the mucosa becomes thickened, and superficial ulcers are seen . Deep ulcerations can appear as "collar-button" ulcers, which indicate that the ulceration has penetrated the mucosa 29/09/2017 Bachelor of Clinical Medicine 140

141. C omplications Massive haemorrhage Toxic megacolon defined as a transverse or right colon with a diameter of >6 cm, with loss of haustration in patients with severe attacks of UC toxic colitis (risk of perforation) Strictures Anal fissures perianal abscesses, hemorrhoids 29/09/2017 Bachelor of Clinical Medicine 141

142. Crohn's Disease Read and make notes Classification Dx Investigationd Management Prevention Nutrition drugs 29/09/2017 Bachelor of Clinical Medicine 142

143. Irritable Bowel Syndrome A functional bowel disorder characterized by abdominal pain or discomfort and altered bowel habits in the absence of detectable structural abnormalities 29/09/2017 Bachelor of Clinical Medicine 143

144. 29/09/2017 Bachelor of Clinical Medicine 144

145. C fs Abdominal Pain Altered bowel habits Gas and Flatulence Upper Gastrointestinal Symptoms Dyspepsia, heart burn, nausea, vomitting 29/09/2017 Bachelor of Clinical Medicine 145

146. Approach to the Patient diagnosis relies on recognition of positive clinical features and elimination of other organic diseases A careful history and physical examination are frequently helpful in establishing the diagnosis 29/09/2017 Bachelor of Clinical Medicine 146

147. Clinical features suggestive of IBS include the following: recurrence of lower abdominal pain with altered bowel habits over a period of time without progressive deterioration, onset of symptoms during periods of stress or emotional upset, absence of other systemic symptoms such as fever and weight l`oss , and small-volume stool without any evidence of blood 29/09/2017 Bachelor of Clinical Medicine 147

148. Investigate to rule out common causes ( ddx ) 29/09/2017 Bachelor of Clinical Medicine 148

149. tx Reassurance and careful explanation of the functional nature of the disorder and of how to avoid obvious food precipitants are important first steps in patient counseling and dietary change. Dietary history may reveal substances (such as coffee, disaccharides, legumes, and cabbage) that aggravate symptoms. 30/09/2017 Bachelor of Clinical Medicine 149

150. Specific tx agents Stool-Bulking Agents High-fiber diets and bulking agents, such as bran or hydrophilic colloid, are frequently used in treating IBS Antispasmodics anticholinergic drugs may provide temporary relief for symptoms such as painful cramps related to intestinal spasm (hyoscine butylbromide ) Antidiarrheal Agents loperamide , 2–4 mg every 4–6 h up to a maximum of 12 g/d, can be prescribed 30/09/2017 Bachelor of Clinical Medicine 150

151. Antidepressant Drugs antidepressant medications have several physiologic effects that suggest they may be beneficial in IBS Antiflatulence Therapy Patients should be advised to eat slowly and not chew gum or drink carbonated beverages Avoiding flatogenic foods, exercising, losing excess weight, and taking activated charcoal Modulation of Gut Flora neomycin dosed at 500 mg twice daily for 10 days rifaximin 400 mg three times daily 30/09/2017 Bachelor of Clinical Medicine 151

152. Chloride Channel Activators Oral lubiprostone Serotonin Receptor Agonist and Antagonists 30/09/2017 Bachelor of Clinical Medicine 152

153. LIVER AND BILLARY TRACT DISEASES Unit 2 of GI medicine 30/09/2017 Bachelor of Clinical Medicine 153

154. Approach to pt A diagnosis of liver disease usually can be made accurately via a careful history, physical examination, application of a few laboratory tests 30/09/2017 Bachelor of Clinical Medicine 154

155. In some circumstances, radiologic examinations are helpful Liver biopsy is considered the criterion standard in evaluation of liver disease but is now needed less for diagnosis than for grading and staging of disease. 30/09/2017 Bachelor of Clinical Medicine 155

156. Liver structure and function liver is the largest organ of the body weighing 1–1.5 kg and representing 1.5–2.5% of the lean body mass located in the right upper quadrant of the abdomen under the right lower rib cage against the diaphragm held in place by ligamentous attachments to the diaphragm, peritoneum, great vessels, and upper gastrointestinal organs 30/09/2017 Bachelor of Clinical Medicine 156

157. majority of cells in the liver are hepatocytes, which constitute 2/3 of the mass of the liver The remaining cell types (1/3) are Kupffer cells (members of the reticuloendothelial system), stellate (Ito or fat-storing) cells, endothelial cells and blood vessels, bile ductular cells, supporting structures 30/09/2017 Bachelor of Clinical Medicine 157

158. Function of hepatocytes synthesis of essential serum proteins (albumin, carrier proteins, coagulation factors,hormonal and growth factors), production of bile and its carriers (bile acids, cholesterol, lecithin, phospholipids), regulation of nutrients (glucose, glycogen, lipids, cholesterol, amino acids), metabolism and conjugation of lipophilic compounds (bilirubin, anions, cations, drugs) for excretion in the bile or urine. 30/09/2017 Bachelor of Clinical Medicine 158

159. Liver function tests (LFTs) are based on these functions The most commonly used liver "function" tests are measurements of serum bilirubin, albumin, and prothrombin time The serum bilirubin level is a measure of hepatic conjugation and excretion , the serum albumin level and prothrombin time are measures of protein synthesis . Abnormalities of bilirubin, albumin, and prothrombin time are typical of hepatic dysfunction 30/09/2017 Bachelor of Clinical Medicine 159

160. Liver Diseases Usually classified as hepatocellular , cholestatic (obstructive), mixed. In hepatocellular diseases (such as viral hepatitis or alcoholic liver disease), features of liver injury, inflammation, and necrosis predominate In cholestatic diseases (such as gallstone or malignant obstruction, primary biliary cirrhosis, some drug-induced liver diseases), features of inhibition of bile flow predominate . In a mixed pattern, features of both hepatocellular and cholestatic injury are present. 30/09/2017 Bachelor of Clinical Medicine 160

161. NB: The pattern of onset and prominence of symptoms can rapidly suggest a diagnosis This is so if major risk factors are considered such as the age and sex of the patient and a history of exposure or risk behaviors . 30/09/2017 Bachelor of Clinical Medicine 161

162. Symptoms of liver disease jaundice, fatigue , itching , right upper quadrant pain, nausea , poor appetite, abdominal distention, intestinal bleeding. 30/09/2017 Bachelor of Clinical Medicine 162

163. Evaluation of pt should be directed at establishing the etiologic diagnosis, estimating the disease severity (grading), establishing the disease stage (staging ). Diagnosis should focus on the category of disease such as hepatocellular, cholestatic , or mixed injury, as well as on the specific etiologic diagnosis Grading refers to assessing the severity or activity of disease—active or inactive, and mild, moderate, or severe Staging refers to estimating the place in the course of the natural history of the disease, acute/chronic ; early or late; precirrhotic , cirrhotic, or end-stage 30/09/2017 Bachelor of Clinical Medicine 163

164. Clinical History should focus on the symptoms of liver disease—their nature, patterns of onset, and progression—and on potential risk factors for liver disease The symptoms of liver disease are grouped C onstitutional symptoms fatigue , weakness, nausea, poor appetite, and malaise L iver-specific symptoms jaundice , dark urine, light stools, itching, abdominal pain, and bloating 30/09/2017 Bachelor of Clinical Medicine 164

165. F atigue most common and most characteristic symptom of liver disease It is variously described as lethargy, weakness, listlessness, malaise, increased need for sleep, lack of stamina, and poor energy The fatigue of liver disease typically arises after activity or exercise and is rarely present or severe in the morning after adequate rest (afternoon versus morning fatigue ). Fatigue in liver disease is often intermittent and variable in severity from hour to hour and day to day 30/09/2017 Bachelor of Clinical Medicine 165

166. Nausea Occurs with more severe liver disease and may accompany fatigue or be provoked by odors of food or eating fatty foods. Vomiting can occur but is rarely persistent or prominent. Poor appetite with weight loss occurs commonly in acute liver diseases but is rare in chronic disease, except when cirrhosis is present and advanced Diarrhea is uncommon in liver disease, except with severe jaundice, where lack of bile acids reaching the intestine can lead to steatorrhea. 30/09/2017 Bachelor of Clinical Medicine 166

167. Right upper quadrant discomfort The pain arises from stretching or irritation of Glisson's capsule, which surrounds the liver and is rich in nerve endings Severe pain is most typical of gallbladder disease, liver abscess, severe venoocclusive acute hepatitis . 30/09/2017 Bachelor of Clinical Medicine 167