ALTERATI

ONI
NGI
TFUNCTI
ON

Lear ningobj ect i

ves
Att heendoft hischapterthe
student swi llbeabl eto:-
-Di scussbackgr oundinformati
on
aboutpept icul cerdiseases(PUD).
-Expl ainpredi sposingfactorsand
pat hogenesi sofPUD.
-Listcl i
nicalmani f
estati
onsand
compl i
cationsofPUD.
-Descr i
becausesand
Pat hophy siologicchangesof
i
nt estinalobst ructi
ons
5.
1.Pept
icUl
cer
sDi
seases(
PUD)

I
ntr
oduct
ion

Pept
iculcerdi
seaser
epr
esent
sa
br
eakinthe

cont
inui
tyoft
hegastr
oint
est
inal
tr
actmucosall
ayer
.

I
tiscommonl
ycategor
izedi
nto
t
woasgastr
icand
duodenalpept
icul
cerdi
seases.

Gastr
icandduodenalpept
icul
cer
s
wi
ththeir

r
emissi
onsandexacer
bat
ions
r
epr
esentachroni
c

heal
thpr
obl
em.

Duodenalul
cer
sar
e5t
o10xmor
e
commont han
gast
ri
cul
cer
.

Ulcer
sinduodenum occuratany
ageandare

f
requent
lyseeninearlyadul
thood.
Whil
eGastri
cul cer
stendtoaffect
t
heoldagegr oupwithpeak

i
nci
dencei
nthe6t
h_7t
hdecade.

Botht
ypesoful
ceraf
fectmen3t
o
4ti
mescompared
t
owomen.

Pept
iculcerscanoccuri
nanyar
ea
ofGIt
ractthati
s

exposedt
oaci
d-pepsi
nsecr
eti
ons.

-Commonsi
tesar
e:-

1.Ulcerat
ioninesophaguscaused
byrefluxofgastr
ic

secr
eti
ons
2.I
nst
omachandduodenum:-t
he
commonsi
tes.

3.I
nMeckel
'sdiver
ti
cul
um t
hat
cont
ainmi
splacedgast
ri
c

t
issue.

Pr
edi
sposi
ngf
act
orsf
orPUD:-

oPept
iculcerrepresent
sabr
eaki
n
t
heconti
nuityofthe
mucosall
ayer.Thef
oll
owi
ng
condi
ti
onsaresomeof

i
ncr
imi
natedpredi
sposi
ngf
act
ors
f
ordev
elopmentof

GImucosalul
cer
ati
on:-

A.Increasedl
evelofmucosal
aggressive

f
act
ors(
Incr
easedaci
dandpepsi
n
pr
oducti
on)B.Inabi
li
tyoft
he
mucosalbar
ri
ertoresi
st

t
hedest
ruct
iveact
ionoft
hegast
ri
c

secr
eti
ons(
enzy
mes&aci
ds)
.

N.B:
-I
tismoreli
kel
ythatbot
hoft
he
abovefact
ors

cont
ri
but
etothedev el
opmentof
pept
icul
cerdi
seases.
A.Increasedaci
dandpepsi
n
production

oIncr
easedpepsi
n-pr
oduct
ionand
HClproduct
ioni
s

i
nfluencedbysev
eralf
act
orsl
ike
neuralandhor
monal

st
imul
ati
on.

ForExampl
e:-
 Thehor
monegast
ri
n:-

Thi
sispr
oducedi
ntheant
rum of
st
omach,i
s

potentst
imulusf
orHCl
product
ion.
Alsogastr
in

hormonehasbeenat
tri
but
edt
othe
fol
lowi
ng

act
ions:-
1.I
ncreasi
ngnumberofaci
dand
pepsi
n

pr
oduci
ngcel
lsi
nst
omach

2.I
ncr
easedsensi
ti
vi
tyofpar
iet
al
cel
lst
ofood

andotherst
imul
ili
keal
cohol
,
caf
fei
ne,

et
cincr
easesHClpr
oduct
ion.
3.Excessi
vev
agalst
imul
ati
on
sti
mulates

HClpr
oduct
ion.

4.Impairedi
nhi
bit
ionofgast
ri
c
secret
ionsasfood

mov
esi
ntoi
ntest
ine.

Neural
sti
mulati
ons: Normal
ly
gast
ri
csecret
ioni
sinhi
bit
edasfood
movesi
ntothei
ntest
inall
umen.
Thi
sref
lex

i
nhi
bit
ionofgast
ri
csecr
eti
onsmay
bei
mpairedi
n

cer
tai
ntypeoful
cer
sknownas
Cushi
ng’
sulcer

(st
ressul
cer
):-
whi
choccuri
n
associ
ati
onwit
h

severebr
aininj
ury
,sev
erebur
nor
neurosur
gery
.
(Bycausi
ngincr
easedcent
ral
sti
mulati
onofvagus

nerv
e, sever
ebr
aini
njur
yand
neurosurger
y

r
esul
ti
ngi
nunr
esponsi
venesst
othe
r
efl
ex

mechani
smst
hatnor
mal
lycont
rol
gast
ri
c
secr
eti
ons)
.

B.I
nabi
li
tyoft
hemucosalBar
ri
ert
o
Resi
stGast
ri
c

Secr
eti
ons

Thedefenseoft
hemucosal
sur
facedependsonan

adequat
ebloodflowandi
ntact
mucosalbarr
ier
s.
Thi
sissui
tabl
etohy
drogeni
on.

Basicabnormal
it
yinper
sonwi
th
gast
ri
c-pepti
c

ulceri
sanincreasedper
meabi
li
tyof
theepit
hel
ial

l
ayeroft
hest
omacht
ohy
drogeni
on.

Thefol
lowi
ngcondi
ti
onsaf
fect
mucosalbar
ri
er
i
ntegr
it
y:-

Chr
onical
lydi
seasedmucosal
membraneis

unabl
etosecr
etesuf
fi
cientmucus
tofor
m an

ef
fect
ivebarr
ier Ref
luxofbi
lef
rom
i
ntest
inetostomachhas

beeni
mpl
icat
edi
npept
icul
cer
.
 Al
sonumbersofdr
ugsar
e
r
ecogni
zedasa

“barr
ier-br
eaker
”bot
haspi
ri
nand
alcoholare

knownt
odamaget
hisbar
ri
er.

Anxi
etyandst
resssy
mpat
het
ic
st
imul
ation

i
nhi
bit
ionofgl
ands(
Brunner
’sgl
and)
t
hati
s
i
mpor t
antt
opr
oducemucus
secr
eti
ons.

I
denti
fi
cat
ionofagr
am-
negat
ive,
S
-
shaped

bacter
ium cal
ledhel
icobact
erpy
lor
i.
Which

col
onizethemucussecr
eti
ng
epi
theli
alcel
lsof

stomachandduodenum anddi
gest
the
pr
otect
ivemucussecr
eti
ng
membranes.

Cli
nicalManif
estat
ionsand
compl i
cat
ionsofPUD

Thecli
nicalmani
festat
ionof
uncompli
catedpepti
c

ul
cerfocusondi
scomf
ortandpai
n.
Pai
n,whichis
descr
ibed,aswani
ng,
gnawi
ngor
crampyli
ke,is

usual
lyr
hyt
hmicandf
requent
ly
occur
swhenthe

stomachi
sempty
.ThePai
nis
usual
lyov
ersmal
lar
ea

neart
hemid-
li
neint
heepi
gast
ri
um
andmayradi
ate

bel
owthecostalmar
ginsi
ntoback
orr
arel
ytothe
r
ightshoul
der
.

Foodorant
iaci
dsr
eli
evet
hepai
n.

Apept
icul
cercanaf
fectoneoral
l
l
ayer
softhe

stomachorduodenum.Anulcermay
penetr
ateonlyt
hemucosalsurf
ace
oritmayextendint
othesmooth

muscl
elay
er.
 Spontaneousremissi
onsand
exacer
bationsare

common.Heal
ingofmuscul
ari
s
l
ayeri
nvol
vi
ng

r
epl
acementwit
hscarr
egener
ati
on
i
soft
enlesst
han

per
fectinwhi
chrepeat
edepi
sodes
oful
cerati
onoccur
.

Compli
cat
ionsofpept
icul
cer
i
ncl
udes:
 Hemorr
hage:-r
esul
tsf
rom
er
osi
onsofthe

mucosa.

-CauseupperGI
-bl
eedi
ng
(Hematemesi
s&

mel
ana)

Per
for
ati
onhemor
rhage:-i
sfr
om
gr
anul
ati
on
t
issueorfr
om er
osi
onofanul
ceri
n
t
oanar t
ery

orv
ein

Obstr
ucti
on:-
iscausedbyedema,
spasm or

f
ormati
onsofscart
issuei
nter
fer
e
wit
hfr
ee

passageofgast
ri
ccont
ent
sthr
ough
thepyl
orus
oradj
acentar
ea.Epi
gast
ri
cful
lness,
heavi
ness

aft
ermealwit
hsev
erecaseof
obstr
uct
ion

vomiti
ngofundi
gest
edf
ood.The
presenceof

anoverni
ghtgast
ri
cresi
dualof
50mlof

undi
gest
edfoodi
ndi
cat
essev
eree
obst
ruct
ion.
 Per
for
ati
on:-occur
swhenanul
cer
er
odes

thr
oughal
lthel
ayer
soft
hest
omach
or

duodenalwal
l
.

Wi
thper
for
ati
on,
GI-
cont
ent
sent
er
t
he

per
it
oneum andcauseper
it
oni
ti
sor
per
for
atedadj
acentst
ruct
uressuch
as

pancr
eas.

Suddenonsetofsev
ereepi
gast
ri
c
pai
nthat

r
adiat
estoback,
rest
lessness,
i
nadequat
e

painrel
ieff
rom eat
ingf
oodsor
taki
ng
antiaci
dsinper
sonswi
thl
ong
standing

hi
stor
yofPUDmaysi
gni
fy
penet
rat
ion.

5.
2Int
est
inalobst
ruct
ion

•Def
ini
ti
ons:-

oAnimpairmentofmov
ementof
i
ntest
inal
cont
enti
ncephal
ocaudaldi
rect
ion.

•Causes

oThecauseofi
ntest
inalobst
ruct
ion
coul
d

becat
egor
izedundert
woheadi
ngs:-

1.Mechani
cal(
dynami
c)causes.

2.Ref
lexpar
aly
tic(
ady
nami
c)
causes.

Mechani
calobst
ruct
ion

Cl
assi
fi
cat
ions

oExt
ri
nsi
cfact
or:-

Adhesi
onsofper
it
oneum

Herni
as
Vol
vul
us(Twi
sti
ngoft
hebowel
l
umen)

oIntr
insi
cfact
ors,
whi
chencr
oach
onthe

pat
encyoft
hebowel
.

Telescopingofthebowel

(
int
ussuscept
ions)

Fecali
mpact
ion
 St
ri
ctur
eoft
hebowel

Tumor
s

Ascar
iasi
sbol
us

Ty
pesofmechani
calobst
ruct
ions:-

oTher
ear
e3-
typesofMechani
cal

obst
ruct
ion
 Si
mpl
eNoal
ter
ati
oni
nbl
ood

f
low

St
rangul
atedt
her
eisobl
it
erat
ion

i
nbl
oodf
low

Cl
osedwhenboweli
sobst
ruct
ed

i
nbothends.Refl
exparaly
tic
(
adynamic)Obst
ruct
ions
oUsual
lyaf
fect
ssmal
lbowelsi
nce
t
he

i
leum hast
henar
rowestl
umenand
i
st he

mostpr
onesi
tet
oobst
ruct
ion.

oPar
aly
tici
leusi
sseenmost
commonly

f
oll
owingabdomi
nal
sur
ger
yor
t
rauma.
oItoccursear
lyi
nthecour
seof
peri
toni
ti
s

andcanresul
tfr
om chemi
cal
i
rri
tat
ion

causedbybi
le,
bact
eri
alt
oxi
ns,

el
ect
rol
ytei
mbal
ance(
hypokal
emi
a)
&

v
ascul
ari
nsuf
fi
ciency
Pat
hophysi
ologyofI
ntest
inal
Obst
ruct
ion

Obst
ruct
ionoft
hei
ntest
inall
umen

Lossoff
lui
dandel
ect
rol
ytest
othe
areawi
thgas

accumul
ati
oni
nthei
ntest
inall
umen
proxi
malt
othe
obstr
uct
edpar
tleadst
odi
stensi
on
ofthepr
oxi
mallumen

Resul
tsindehydr
ati
onsand
hypov
olemicshock.The

mechanismsofdehy dr
ati
onsi
n
i
ntest
inalobst
ruct
ionsare:
-

1.I
ntest
inalobstr
uct
ioni
nter
fi
les
wit
hreabsorpti
onof7to8
l
it
ersofel
ect
rol
yter
ichext
racel
lul
ar
f
lui
din

smal
lbowel
.

2.Losti
nthevomitusof7l
it
erst
o8
l
iter
swhichrepr
esent

abouthal
foft
heext
racel
lul
arf
lui
d
vol
umeofan

averageadul
tcanoccuri
n24hour
s
orless
fol
lowingacutei
ntest
inal
obstr
uction.

3.Thepat
ientcannotdr
inkf
lui
ds.

I
funt
reated,t
hedist
enti
onr
esul
ti
ng
f
rom bowelobst
ruct
ion

tendstoperpet
uat
eitsel
fbycausi
ng
atonyofthebowel&

f
urt
herdi
stensi
onisaggrav
atedby
t
heaccumulati
onofgases.
About70%oft
hesegasesar
e
est
imatedt
obedueto

swall
owedai
r.Asdist
ensi
onmov
es
proxi
mal
lyi
nvolv
ing

addi
ti
onalsegment
sofbowel
.

Theincreasedpr
essur
ewi
thi
nthe
i
ntesti
nallumen

compromisemucosalbl
oodf
low
necr
osis/exudat
ion
ofthebowelev
ent
ual
lyst
rangul
ati
on,
gangrenous

changeandul
ti
mat eperf
orat
ionof
bowelwit
hbacter
ialover

growthRel
easeofendot
oxi
n&
bacter
imi
a

SEPSI
S.

Cl
ini
calMani
fest
ati
onsofI
ntest
inal
Obst
ruct
ions
Themanifest
ati
onofint
est
inal
obst
ruct
iondependsonthe

degreeofobstr
uct
ionandit
s
durati
on.Wit
hacuteobst
ruct
ion

theonseti
susual
lysuddenand
dramati
cbutwit
hchronicone

onseti
smoregradual.Thecar
dinal
symptomsofi
ntesti
nal

obst
ruct
ionar
e:
1.Pai
n:-whi
chiscol
icky
,especi
all
y
wit
hmechanical

obstr
ucti
on.Iti
sduet
oincr
eased
peri
stal
sisasthe

i
ntesti
neattemptst
omov
ethe
contentf
orward.

-Alsot
her
eisi
ncr
easedbowel
sound.

2.Absolut
econsti
pat
ion:-f
ail
uret
o
passfeacesand
f
lat
us.3.Abdom inaldistenti
on:-duetogases

accumul
ati
onsandat
oni
aoft
he
Smoothmuscles

i
nthei
ntest
inall
umen

4.Vomit
ing:-l
eadstoflui
dand
el
ectr
oly
teimbalance.

-Thevomi
tusmaycont
ainf
ecul
ent
matter
(
off
ensi
ve)
.

Si
gnsofGangrenousChangesor
St
rangul
ati
ons:
-

Ifanacuteint
esti
nalobst
ruct
ionl
eft
untr
eatedforlong

durat
ion,usual
lyabov
e72hour
s,
str
angulati
onsand

gangrenouschangei
sther
ule.The
fol
lowingare
cl
ini
calsi
gnsofgangr
enous
changes:
-

-Thepati
entbecomesweakand
prost
rat
ed.

-Dev
elopmentoff
ever

-Tachy
car
dia

-Absenceofper
ist
alsi
s(bowel
sound)
-I
ncr
easedabdomi
nalt
ender
ness.

N.
B:-withdevel
opmentof
st
rangul
ati
onsmortal
it
yrat
eis

i
ncr
easedby25%