Digestive System Disorders

Common Manifestations of
Digestive System Disorders
Anorexia, Nausea, Vomiting
May be signs of digestive disorders or other conditions elsewhere in the
body
◦ Systemic infection
◦ Uremia
◦ Emotional responses
◦ Motion sickness
◦ Pressure in the brain
◦ Overindulgence of food, drugs
◦ Pain
Anorexia, Nausea, Vomiting
(Cont’d)
Anorexia and vomiting
◦ Can cause serious complications
◦ Dehydration, acidosis, malnutrition

Anorexia
◦ Often precedes nausea and vomiting

Nausea
◦ Unpleasant subjective feeling
◦ Simulated by distention, irritation, inflammation of digestive tract
◦ Also stimulated by smells, visual images, pain, and chemical toxins and/or drugs
Anorexia, Nausea, Vomiting
(Cont’d)
Vomiting (emesis)
◦ Vomiting center located in the medulla
◦ Coordinates activities involved in vomiting
◦ Protects airway during vomiting
◦ Forceful expulsion of chyme from stomach
◦ Sometimes includes bile from intestine
Diarrhea
Excessive frequency of stools
◦ Usually of loose or watery consistency

May be acute or chronic

Frequently with nausea and vomiting when infection or inflammation
develops
May be accompanied by cramping pain
Prolonged diarrhea may lead to dehydration, electrolyte imbalance,
acidosis, malnutrition
Common Types of
Diarrhea
Large-volume diarrhea (secretory or osmotic)
◦ Watery stool resulting from increased secretions into intestine from the plasma
◦ Often related to infection
◦ Limited reabsorption due to reversal of normal carriers for sodium and or
glucose

Small-volume diarrhea
◦ Often due to inflammatory bowel disease
◦ Stool may contain blood, mucus, pus
◦ May be accompanied by abdominal cramps and tenesmus
Common Types of Diarrhea
(Cont’d)
Steatorrhea – “fatty diarrhea”
◦ Frequent bulky, greasy, loose stools
◦ Foul odor
◦ Characteristic of malabsorption syndromes
◦ i.e., celiac disease or cystic fibrosis
◦ Fat usually the first dietary component affected
◦ Presence interferes with digestion of other nutrients.
◦ Abdomen often distended
Blood in Stool
Blood may occur in normal stools, with diarrhea, constipation, tumors, or
inflammatory conditions.
◦ Frank blood
◦ Red blood – usually from lesions in rectum or anal canal
◦ Occult blood
◦ Small hidden amounts, detectable with stool test
◦ May be caused by small bleeding ulcers
◦ Melena
◦ Dark-colored, tarry stool
◦ May result from significant bleeding in upper digestive tract
Gas
From swallowed air, e.g., drinking from a straw
Bacterial action on food
Foods or alterations in motility
Excessive gas causes
◦ Eructation
◦ Borborygmus
◦ Abdominal distention and pain
◦ Flatus
Constipation
Less frequent bowel movements than normal
Small hard stools
Acute or chronic problem
May be due to decreased peristalsis
◦ Increased time for reabsorption of fluid

Periods of constipation may alter with periods of diarrhea.

Chronic constipation may cause hemorrhoids, anal fissures, or
diverticulitis.
Causes of Constipation
Weakness of smooth muscle due to age or illness
Inadequate dietary fiber
Inadequate fluid intake
Failure to respond to defecation reflex
Immobility
Neurologic disorders
Drugs (i.e., opiates)
Some antacids, iron medications
Obstructions caused by tumors or strictures
Fluid and Electrolyte
Imbalances
Dehydration and hypovolemia are common complications of digestive
tract disorders.
Electrolytes
◦ Lost in both vomiting and diarrhea

Acid-base imbalances
◦ Metabolic alkalosis
◦ Results from loss of hydrochloric acid with vomiting
◦ Metabolic acidosis
◦ Severe vomiting causes a change to metabolic acidosis due to the loss of bicarbonate of duodenal
secretions.
◦ Diarrhea causes loss of bicarbonate.
Pain – Visceral Pain
Burning sensation
◦ Inflammation and ulceration in upper digestive tract

Dull, aching pain

◦ Typical result of stretching of liver capsule

Cramping or diffuse pain

◦ Inflammation, distention, stretching of intestines

Colicky, often severe pain

◦ Recurrent sooth muscle spasms or contraction
◦ Response to severe inflammation or obstruction
Pain – Somatic Pain
Somatic pain receptors directly linked to spinal nerves
◦ May cause reflex spasm of overlying abdominal muscles

Steady, intense, often well-localized abdominal pain

Involvement or inflammation of parietal peritoneum
“Rebound tenderness” – identified over area of inflammation when
pressure is released
Pain – Referred Pain
Common phenomenon
Pain is perceived at a site different from origin.
Results when visceral and somatic nerves converge at one spinal cord
level
Source of visceral pain is perceived as the same as that of the somatic
nerve.
May assist or delay diagnosis depending on problem
Pain – Referred Pain
(Cont’d)
Malnutrition
May be limited to a specific nutrient or general
Causes of limited – specific problem
◦ Vitamin B12 deficiency
◦ Iron deficiency

Causes of generalized malnutrition

◦ Chronic anorexia, vomiting, diarrhea
◦ Other systemic causes
◦ Chronic inflammatory bowel disorders
◦ Cancer treatments
◦ “Wasting syndrome”
◦ Lack of nutrients available
Basic Diagnostic Tests
Radiographs
◦ Contrast medium may be used

Ultrasound
◦ May show unusual masses

Computed tomographic (CT) scans

Magnetic resonance imaging (MRI)
CT and MRI may use radioactive tracers.
◦ Can be used for liver and pancreatic abnormalities
Basic Diagnostic Tests
(Cont’d)
Fiberoptic endoscopy used in upper GI tract
◦ Biopsy may be done during procedures.

Sigmoidoscopy and colonoscopy

◦ Biopsy and removal of polyps may be done

Laboratory analysis of stool specimens

◦ Check for infection, parasites and ova, bleeding, tumors, malabsorption

Blood tests
◦ Liver function, pancreatic function, cancer markers
Upper Gastrointestinal
Tract Disorders
Dysphagia
Difficulty swallowing
Causes
◦ Neurologic deficit
◦ Muscular disorder
◦ Mechanical obstruction

Results/presentation
◦ Pain with swallowing
◦ Inability to swallow larger pieces of solid material
◦ Difficulty swallowing liquids
Dysphagia (Cont’d)
Neurologic deficit
◦ Infection
◦ Stroke
◦ Brain damage
◦ Achalasia
◦ Failure of the lower esophageal sphincter to relax due to lack of innervation

Muscular disorder
◦ Impairment from muscular dystrophy
Dysphagia (Cont’d)
Mechanical obstruction
◦ Congenital atresia
◦ Developmental anomaly
◦ Upper and lower esophageal segments are separated
◦ Stenosis
◦ Narrowing of the esophagus
◦ May be developmental or acquired
◦ May be secondary to fibrosis, chronic inflammation, ulceration, radiation therapy
◦ Stenosis or stricture may also result from scar tissue.
◦ May require treatment with repeated mechanical dilation
Dysphagia (Cont’d)
Mechanical obstruction (Cont’d)
◦ Esophageal diverticula
◦ Outpouchings of the esophageal wall
◦ Congenital or acquired following inflammation
◦ Causes irritation, inflammation, scar tissue
◦ Signs include dysphagia, foul breath, chronic cough, hoarseness
◦ Tumors
◦ May be internal or external
Causes of Dysphagia
Causes of Dysphagia
(Cont’d)
Hiatal Hernia
Part of the stomach protrudes into the thoracic cavity.
Sliding hernia
◦ More common type
◦ Portion and part of stomach and gastroesophageal junction slide up above the
diaphragm

Rolling or paraesophageal hernia

◦ Part of the fundus of the stomach moves up through an enlarged or weak
hiatus in the diaphragm and may become trapped.
Types of Hiatal Hernia
Hiatal Hernia (Cont’d)
Food may lodge in pouch of the hernia
◦ Causes inflammation of the mucosa
◦ Reflux of food up the esophagus
◦ May cause chronic esophagitis

Signs
◦ Heartburn or pyrosis
◦ Frequent belching
◦ Increased discomfort when laying down
◦ Substernal pain that may radiate to shoulder and jaw
Gastroesophageal Reflux
Disease
Periodic reflux of gastric contents into distal esophagus causing erosion
and inflammation
Often seen in conjunction with hiatal hernia
Severity depends on competence of the lower esophageal sphincter.
Delayed gastric emptying may be a factor.
Avoidance of
◦ Caffeine, fatty/spicy foods, alcohol, smoking, certain drugs

Use of medication may reduce reflux and inflammation.

Gastritis – Acute
Gastritis
Gastric mucosa is inflamed.
May be ulcerated and bleeding
May result from
◦ Infection by microorganisms
◦ Allergies to foods
◦ Spicy or irritating foods
◦ Excessive alcohol intake
◦ Ingestion of aspirin or other NSAIDs
◦ Ingestion of corrosive or toxic substances
◦ Radiation or chemotherapy
Gastritis – Acute Gastritis
(Cont’d)
Basic signs of gastrointestinal irritation
◦ Anorexia, nausea, vomiting may develop
◦ Hematemesis due to bleeding
◦ Epigastric pain, cramps or general discomfort
◦ With infection, diarrhea may develop.

Acute gastritis is usually self-limiting.

◦ Complete regeneration of gastric mucosa
◦ Supportive treatment with prolonged vomiting
◦ May require treatment with antimicrobial drugs
Gastritis – Chronic
Gastritis
Characterized by atrophy of stomach mucosa
◦ Loss of secretory glands
◦ Reduced production of intrinsic factor

H. pylori infection is often present.

Signs may be vague.
◦ Mild epigastric discomfort, anorexia, intolerance for certain foods

Increased risk of peptic ulcers and gastric carcinoma

Certain autoimmune disorders are associated with one type of chronic
gastric atrophy.
Gastritis –
Gastroenteritis
Inflammation of stomach and intestine
Usually caused by infection
May also be caused by allergic reactions to food or drugs
Microbes can be transmitted by fecally contaminated
food, soil, and/or water
◦ Most infections are self-limiting.
◦ Serious illness may result in compromised host or virulent organisms.
◦ May cause epidemic outbreaks in refugee or disaster settings
◦ Safe sanitation essential for prevention
Peptic Ulcer – Gastric
and Duodenal Ulcers
Most are due to H. pylori infection.
Occur most commonly in the proximal duodenum (duodenal ulcers)
Also found in the antrum of the stomach (gastric ulcers)
Development begins with breakdown of mucosal barrier.
◦ Decreased mucosal defense
◦ More common in gastric ulcer development
◦ Increased acid secretion predominant factor in duodenal ulcers
Peptic Ulcer – Common
Locations
Peptic Ulcer – Gastric
and Duodenal Ulcers (Cont’d)
Damage to mucosal barrier predisposes to development of ulcers and is
associated with
◦ Inadequate blood supply
◦ Caused by vasoconstriction (by stress, smoking, shock; circulatory impairment in older adults; scar
tissue; anemia)
◦ Interferes with rapid regeneration of epithelium
◦ Excessive glucocorticoid secretion or medication
◦ Ulcerogenic substances break down mucus layer.
◦ Aspirin, NSAIDs, alcohol
◦ Atrophy of gastric mucosa
◦ Chronic gastritis
Peptic Ulcer – Gastric
and Duodenal Ulcers (Cont’d)
Increased acid-pepsin secretions
◦ Increased gastrin secretion
◦ Increased vagal stimulation
◦ Increased sensitivity to vagal stimuli
◦ Increased number of acid-pepsin secretory cells in the stomach (genetic
anomaly)
◦ Increased stimulation of acid-pepsin secretion
◦ Alcohol, caffeine, certain foods
◦ Interference with normal feedback mechanisms
◦ Rapid gastric emptying
Peptic Ulcer – Gastric
and Duodenal Ulcers (Cont’d)
Complications with peptic ulcer
◦ Hemorrhage
◦ Due to erosion of blood vessels
◦ Common complication
◦ May be the first sign of a peptic ulcer
◦ Perforation
◦ Ulcer erodes completely through the wall.
◦ Chyme can enter the peritoneal cavity.
◦ Results in chemical peritonitis
◦ Obstruction
◦ May result later due to the formation of scar tissue
Peptic Ulcer – Gastric
and Duodenal Ulcers (Cont’d)
Signs and symptoms
◦ Epigastric burning or localized pain usually following stomach emptying

Diagnostic tests
◦ Fiberoptic endoscopy
◦ Barium x-ray
◦ Endoscopic biopsy

Treatment
◦ Combination of antimicrobial and proton pump inhibitor to eliminate H. pylori
◦ Reduction of exacerbating factors
Disorders of the Liver and
Pancreas
Hepatitis
Inflammation of the liver
Alcoholic
◦ Fatty liver

Idiopathic
◦ Fatty liver

Viral hepatitis
◦ Local infection

Infection elsewhere in body

◦ e.g., infectious mononucleosis or amebiasis

Chemical or drug toxicity

Viral Hepatitis
Cell injury results in inflammation and necrosis in the liver.
◦ Degrees of inflammation and damage vary.

Liver is edematous and tender.

Causative viruses
◦ Hepatitis A virus (HAV)
◦ Hepatitis B virus (HBV)
◦ Hepatitis C virus (HCV)
◦ Hepatitis D virus (HDV)
◦ Hepatitis E virus (HEV)
Viral Hepatitis (Cont’d)
Hepatitis A (HAV)
◦ Small RNA virus
◦ Infectious hepatitis
◦ Transmitted by fecal-oral route in areas of inadequate sanitation or
hygiene
◦ Often from contaminated water or shellfish
◦ Sexual transmission has occurred during anal intercourse
◦ Acute but self-limiting infection
◦ No carrier or chronic state
◦ Fecal shedding of virus before onset of signs
◦ Vaccine available for travelers, food care workers, and health care
workers
Viral Hepatitis (Cont’d)
Hepatitis B (HBV)
◦ Partially double-stranded DNA virus
◦ Over 50% of HIV-positive cases are positive for HBV.
◦ 50% of cases are asymptomatic but contagious due to carrier state.
◦ Chronic inflammation can occur.
◦ Transmission primarily by infected blood
◦ Sexual transmission has been noted.
◦ Tattooing and body piercing may transmit the virus.
◦ Vaccine available and routinely given to children
Viral Hepatitis (Cont’d)
Hepatitis C (HCV)
◦ Single-stranded RNA virus
◦ Most common type transmitted by blood transfusion
◦ May exist in a carrier state
◦ About half the cases enter the chronic state.
◦ Increases risk of hepatocellular carcinoma
◦ Treated with interferon injections
Viral Hepatitis (Cont’d)
Hepatitis D (HDV)
◦ Also called delta virus
◦ Incomplete RNA virus
◦ Requires HBV to replicate and produce active infection
◦ HDV infection increases severity of HBV infection
◦ Transmitted by blood

Hepatitis E (HEV)
◦ Single-stranded RNA virus
◦ Transmitted by oral-fecal route
◦ No chronic or carrier state
Viral Hepatitis – Signs and
Symptoms
Preicteric stage
◦ Fatigue and malaise
◦ Anorexia and nausea
◦ General muscle aching++

Icteric stage
◦ Onset of jaundice
◦ Stools light in color, urine becomes darker
◦ Liver tender and enlarged, mild aching pain

Posticteric stage – recovery stage

◦ Reductions in signs
◦ Weakness persists for weeks
Course of Hepatitis B
Infection
Viral Hepatitis (Cont’d)
Only body defense is formation of antibodies via vaccination.
Supportive measures
◦ Rest, diet high in protein, carbohydrate, and vitamins

Chronic hepatitis can be treated with interferon.

◦ Decrease of viral replication
◦ Effective in only 30% to 40% of individuals
◦ Drug combination (slow-acting interferon and antiviral drug) more effective
Lower Gastrointestinal
Tract Disorders
Celiac Disease
Malabsorption syndrome
Primarily a childhood disorder
◦ May occur in adults in middle age

Appears to have genetic link

Defect in intestinal enzyme
◦ Prevents further digestion of gliadin (breakdown product of gluten)
◦ Toxic effect on intestinal villi – atrophy of villi
◦ Malabsorption and malnutrition result.
Celiac Disease (Cont’d)
First signs appear when cereals are added
◦ About 4 to 6 months of age

Manifestation
◦ Steatorrhea, muscle wasting, failure to gain weight
◦ Irritability and malaise common

Diagnosed by a series of blood tests

Gluten-free diet for treatment
◦ Intestinal mucosa returns to normal after a few weeks without gluten intake.
Chronic Inflammatory Bowel
Disease
Crohn disease and ulcerative colitis are chronic inflammatory bowel
diseases (IBDs).
Causes unknown
Genetic factor appears to be involved.
Crohn disease – often during adolescence
Ulcerative colitis – second or third decade
Many similarities between Crohn disease and ulcerative colitis
Inflammatory Bowel
Disease
Crohn Disease
May affect any area of the digestive tract
◦ Most frequently the small intestine

Inflammation occurs in characteristic distribution.

◦ “Skip lesions” – affected areas separated by areas of normal tissue

Progressive inflammation and fibrosis may cause obstructed areas.

◦ Damaged walls impair processing and absorption of food.
◦ Inflammation stimulates intestinal motility.
Crohn Disease (Cont’d)
Interference with digestion and absorption
◦ Hypoproteinemia, avitaminosis, malnutrition, possibly steatorrhea

Other complications
◦ Adhesions between loops may form and fistulas may develop.

Children
◦ Delayed growth and sexual maturation

Glucocorticoid used in treatment

Crohn Disease (Cont’d)
Ulcerative Colitis
Inflammation starts in the rectum
Progresses through the colon
Mucosa and submucosa are inflamed.
◦ Tissue destruction interferes with absorption of fluid and electrolytes in the
colon.

Severe acute episodes – toxic megacolon may develop

Diarrhea marked with up to 12 stools per day.
◦ Contains blood and mucus
◦ Accompanied by cramping pain
Acute Ulcerative Colitis