GIT 2 New Dr. Basu. Topic Malabsorption Diarrhea and Dysentery IBD –Ulcerative colitis –Crohns...
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Transcript of GIT 2 New Dr. Basu. Topic Malabsorption Diarrhea and Dysentery IBD –Ulcerative colitis –Crohns...
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GIT 2
New
Dr. Basu
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Topic
• Malabsorption
• Diarrhea and Dysentery
• IBD– Ulcerative colitis– Crohns disease
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Malabsorption : Classification
• Diagnosis: Steatorrhea, fat soluble vitamin Deficiency, protein and other deficiency.
1. Celiac sprue
2. Whipple disease
3. Disaccharide deficiency
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Celiac sprueCeliac sprue
(chronic sprue)
Antigen involved: gluten. Genetic- HLA-DQ2 or HLA-DQ8.
Morphology Atrophy of Villi, increased number of intraepithelial lymphocytes ( CD4 and CD8 cells).
Clinical Diarrhea, flatulence, weight loss, and fatigue, dermatitis
Respond to gluten free diet.
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Atrophy of VilliNormal
Complication of celiac sprue: Dermatitis Herpitiformis and NHL.
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Tropical sprue
• Definition : malabsorption due to unknown ( ? Infection) etiology.
• Location: Caribbean and South America
• Treatment: antibiotics and B12 supplements.
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WHIPPLE DISEASE
WHIPPLE DISEASE
Etiology: Bacterium Tropheryma whippelii
Morphology Macrophages contain PAS-positive, diastase-resistant granules and rod-shaped bacilli on electron microscopy
Other organ involvement
GIT, CNS, Joint and lymph nodes
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Clinical Features
Age: 40-50 yr.
Malabsorption, Arthropathy, psychiatric complaints and Lymphadenopathy.
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Electron microscopyLight microscope (H&E)Foamy macrophage in villi.
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LACTASE DEFICIENCY
Etiology : Atrophy of the apical villous cells>deficiency of lactase.Clinical :
The infants develop explosive, watery, frothy stools and abdominal distention.Osmotic diarrhea with milk product.
Termination of which result in recovery.
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Vitamin deficiency
Vitamin A Night blindness, xerophthalmia, blindness, Squamous metaplasia, infection.
Vitamin K Bleeding diathesis- not corrected by k injection.
Vitamin D Rickets in children, Osteomalacia in adults.
Vitamin E Spinocerebellar degeneration
Vitamin B12 Megaloblastic pernicious anemia and myelin loss of spinal cord tracts.
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DIARRHEA AND DYSENTERY
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DIARRHEA AND DYSENTERY
• DIARRHEA Def; An increase in stool mass, stool frequency, and/or stool fluidity are perceived as diarrhea.
• DYSENTERY: Dysentery is a severe diarrhea illness often associated with blood in the feces.
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Diseases
Viral enterocolitis Rota virus (dsRNA): child and self limiting.
Adenovirus (dsDNA): adult /child
E. coli - Shiga-like toxin (Undercooked beef products: hamburger)
Hemorrhagic colitis and
Hemolytic-Uremic syndrome (HUS): Hemolysis, Acute Renal failure and DIC.
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Others
• Staphylococcus aureas : – Source is milk product and fatty food → Acute
explosive Exudative diarrhea.– Within a few hours (1-6 hr)
• Vibrio cholera: – Source is Water → Watery diarrhea, cholera,
pandemic spread.– Morphology of GI: normal mucosa
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Cholera: pathogenesis of diarrhea
Cholera toxin A1↓
A1+ ADP-ribosylation factors (ARF)↓
catalyzes G protein ↓
stimulates adenylate cyclase ↓
high levels of intracellular cAMP ↓
stimulates secretion of chloride and bicarbonate, with associated sodium and water secretion.
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Others Salmonella enteritidis→
Milk, beef, eggs, poultry
Self limiting diarrhea / dysentery pain, bacteremia.
Incubation: 12 to 72 hr
Shigella: Person-to-person. Milk, poultry
S. flexneri infection produce Reiter syndrome (chronic arthritis , red eye- conjunctivitis).
Fever, pain, mucosal ulcer.
Exudative diarrhea ,dysentery, epidemic spread
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Clostridium difficile
Clostridium difficile →
Following antibiotic use, nosocomial acquisition: Cytotoxin, local invasion
Fever, pain, bloody diarrhea, pseudo membrane formation over mucosa.
Neural reflex pathways increases epithelial fluid secretion In addition to
production intracellular cAMP
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Pseudomembranous colitis from C. difficile infection morphology
Study unknown picture
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Campylobacter Enterocolitis
Source: dog, ingestion of improperly cooked chicken.
Clinical: Diarrhea, dysentery.
Complications:
Reactive arthritis in HLA-B27 carriers
Guillain-Barré syndrome- myelin loss (PNS).
C. jejuni: immunoproliferative small intestinal disease.
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Amebiasis
Agent Entamoeba histolytica (ameba)
Route Fecal oral
Morphology Produce flask shaped ulcer in submucoca.
Clinical features
Abdominal pain, bloody exudative diarrhea, or weight loss and amebic liver abscess- right upper Q pain.
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Rest a while
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Other intestinal disorders
• Necrotizing Enterocolitis
• Idiopathic Inflammatory Bowel Disease
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Necrotizing Enterocolitis
Definition An acute, necrotizing inflammation of the small and large intestines
Age Neonate : premature or of low birth weight, when infants are started on oral foods
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Necrotizing Enterocolitis
Pathogenesis: factor• Intestinal ischemia
Clinical course : Bloody stools, abdominal distention, and development of circulatory collapse.
Site: involves the terminal ileum, cecum, and right colon.
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Morphology of the gut: gross and micro
• Distended, friable, and congested, or it can be frankly gangrenous.
• Accompanying peritonitis may be seen.
• Morphology: sub mucosal gas bubbles formation.
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Distended intestine
Submucosal gas bubbles
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Prognosis
• High mortality
• Post-NEC stricture is COMMON.
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Idiopathic Inflammatory Bowel Disease
• Type
• Pathogenesis
• Comparative morphology of these two diseases
• Complications and clinical features
• Diagnosis
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IBD• Types:
– Crohns disease– Ulcerative colitis
• Pathogenesis:A. Exaggerated local CD4 T-Cell immune
response- damage to mucosa
B. Inflammation
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Crohn disease
• Features:– Occur any part of GIT– Transmural inflammation .– Noncaseating granulomas.– Fissuring with formation of fistulae.– Smoking is a risk factor.– Recurrent diarrhea, pain, fever common.– Blood in stool 50%.
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Ulcerative colitis
• Features:
– Disease limited to the colon and affecting only the mucosa and sub mucosa.
– Smoking is a risk factor.
– Bloody mucoid diarrhea more common.
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Gross Crohn disease ( gross) Ulcerative colitis ( gross)
Any part of bowel : common in ileocecal junction (regional ileitis)
Large intestine: Pan colitis.
Rectum→ colon: back wash ileitis
Produce “skip” lesions.
Transmural inflammation.
No skip lesion, entire length of bowel is involved.
Mucosal involvement
Cobblestone effect Pseudo polyps
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GrossCrohn disease ( gross) Ulcerative colitis
( gross)
Diseased wall is rubbery and thick
Mural thickening does not occur in UC
Linear ulceration Broad-based ulceration
Mesenteric fat wraps around the bowel surface (creeping fat).
No such features
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Crohn disease : Diseased wall is rubbery and thick and lumen is narrow that give rise to
String sing on X-ray
Study unknown picture
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Gross of Ulcerative colitis :Pseudopolyps
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Microscopy of IBD
Crohn disease Ulcerative colitis
Non Caseating granuloma
Crypt abscess
Pseudopolyps
Dysplasia +
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Ulcerative colitis; crypt abscess and glandular
architectural distortion and dysplasia.
Study unknown picture
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IBD: complication
Ulcerative colitis Crohn's
Complication:
Toxic megacolon
Adenocarcinoma.
Complication:
Fistula and fissure, obstruction
Fistula with other organ like U. Bladder, vagina and, skin (Enteroculaneous fistula)
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Toxic mega colon in UC
No motility, lead pipe
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Crohn disease: Fissure
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Extra intestinal manifestation of IBD
Crohn disease Ulcerative colitis
Migratory poly arthritis ++.
Aphthous ulcer.
Migratory poly arthritis ++++
Uveitis++++++++
Erythema nodosum (painful skin lesion- show similar granuloma)
Hepatic primary sclerosing Cholangitis +++++++
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Diagnosis/ treatment of IBD
Crohn disease Ulcerative colitis
Surgery not helpful Surgery helpful with steroid
pANCA : + pANCA: ++++++++,
HLA B27
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Irritable Bowel Syndrome
• Intrinsic motility disorder ( ? Due to foods, stress- serotonin).
• Clinical: altered bowel habits, frequently suffering from constipation, diarrhea, or both.
• The episodes may subside with a bowel movement
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Thank you