The Abdominal Organs

GI, Liver, Gallbladder, and Pancreas

AH 120

THE GI System

Congenital Defects

Cleft Lip & Cleft Palate

Incomplete fusion of embryonic facial segments

Cleft Lip & Cleft Palate (cont.)

• Etiology: heredity, dietary deficiencies during pregnancy, maternal alcoholism, maternal infection(s) during pregnancy, idiopathic

• S & S: cleft clip causes some feeding impairment. Cleft palate causes significant feeding impairment, ear infections, aspiration, and speech disturbances

• Treatment: Primary is surgical repair as soon as infant is able to tolerate surgery.

Esophageal Atresia and Tracheo-Esophageal Fistula

Esophageal atresia = incomplete esophagus, often ending as a blind pouch. T-E fistula = abnormal communication between esophagus and trachea. These can occur together or separately.

Esophageal Atresia & T-E Fistula (cont.)

Etiology: similar to cleft lip and palateManifestations: • Esophageal atresia – frequent regurgitation of

feedings, failure to thrive• T-E Fistula – airway obstruction when feeding,

aspiration pneumoniaTreatment: Surgical repair

• Isolate trachea prior to surgery with cuffed, endotracheal tube. Esophageal atresia may need gastrostomy feeding tube prior to surgery

Neoplasia in the Oral Cavity and the Esophagus

Leukoplakia

• Hyperplastic cell growth of hard-white squamous tissue in the mucus membrane of the oral cavity

• Etiology: chronic irritation• Smoke, chewing tobacco,

irritating liquids or food

• Leukoplakia is often a precancerous sign!

Oral Cancer

• Malignant epidermoid or lymphocytic tumors in the cheek, lip, gum, or tongue

• Etiology: chronic irritation, alcohol, dental problems

• Manifestations: cosmetic concerns, interference with eating and speaking, and, sometimes breathing

• Treatment: Surgical resection with chemo and radiation therapy• Surgery can be very

mutilating!

Esophageal Cancer

• Usually squamous cell carcinoma or adenocarcinoma that occurs in the lower portion

• Etiology: chronic irritation• Tobacco, alcohol, poor dental

health

• Manifestations:pain, dysphagia and indigestion, feeling that something is “stuck” after eating

• Treatment: surgical resection of esophagus, chemo and radiation

Inflammatory Diseases of the GI Tract

Gastritis• Inflammation of the gastric

mucosa that can be chronic or acute• Acute causes edema and some

superficial erosion• Chronic may cause hypertrophy

or atrophy of mucosa• Atrophy may lead to

pernicious anemia and/or gastric cancer

• Etiology: infection from contaminated food/water, dietary “indiscretion”, chemical irritation• Excessive alcohol, coffee,

smoking, drugs

Gastritis (cont.)

Manifestations:• Abdominal pain• Intense N & V

• Possible hematemesis

• Fever (if acute)• Chronic manifestations are much milder or absentTreatment: Supportive care; may need antibiotics for

infectious causes• Acute often resolves in 24-36 hours

Crohn’s DiseaseRegional Enteritis

• A chronic inflammatory disease that occurs in patches, usually in the terminal ileum and colon• Characterized by periods of

remission and exacerbation

• Etiology: unknown but may be due to combination of dietary, infectious, and autoimmune factors

• Pathology- patchy thickening of the intestinal wall with possible erosion/ulceration

Crohn’s Disease (cont.)Manifestations

During exacerbation:• Fever, abdominal

pain,diarrhea

Complications:• Bowel obstruction• Peritonitis (if

erosion/ulceration occurs

• Fistulas

Crohn’s DiseaseTreatment

• Anti-inflammatory drugs to prevent exacerbation

• Diet – eliminate foods that trigger exacerbation

• Surgery – repair of fistulas; resection of sights of exacerbations• May be simple end to end anastomosis,

ileostomy, or colostomy

GastroenteritisGastroenterocolitis

• Acute inflammation throughout the stomach and small and large intestine

• Etiology: infection, dietary indiscretion, stress

• S & S; Abdominal pain and cramps, borborygmi, N & V, diarrhea

• Treatment: Supportive; maintain hydration;treat any infectious agents

Gastric/Duodenal Ulcers

• Circumscribed erosion of the mucus membrane that usually occurs in the lesser curvature of the stomach and in the duodenum (just past the pyloric valve)

• Etiology: most are due to infection by a bacteria, Helicobacter• Stress, diet, smoking, alcohol, drugs, etc,

aggravate and encourage ulcer activity, but probably do not cause them

Acute Ulcer

• Red, swollen areas that may have blood in the center of the lesion

Sub-acute Ulcer

• Erosion is through mucosa and into muscle layer

• Center of lesion usually has pus in it

Chronic Ulcer

• Fibrous, scar tissue is present with the erosions

Ulcer: Signs & Symptoms

• Painful, gnawing sensation in stomach that is usually relieved by intake of food

• Increased gastric acidity

• Perforation may lead to peritonitis and hemorrhage (which leads to shock)

Ulcer Treatment

• Antibiotics for Helicobacter• Usually Amoxicillin tried first

• Antacids

• Dietary control

• No smoking!

• Surgery for perforations/ erosions that cause bleeding

Ulcerative Colitis• A chronic, diffuse

inflammatory and ulcerative disease (with periods of remission and exacerbation) that normally starts in the rectosigmoid area and spreads to envelop a large portion of the entire bowel• Note it is similar to Crohn’s,

but Crohn’s is patchy inflammation, not diffuse

• Leads to abscesses, necrosis, and possible ulceration with perforation

Ulcerative Colitis (cont.)

• Etiology – most likely auto-immune • Stress, poor, diet, and

infection may aggravate condition and cause exacerbations

• S & S – painful & bloody diarrhea, weight loss, anemia and shock from internal blood loss, peritonitis (if perforation occurs)• Patients with this disease are

at high risk for developing colon cancer

Treatment

• Diet– minimal raw fruits and vegetables, no milk/milk products

• Steroids

• Surgery – may need to resect chronically inflamed areas• May necessitate a

colostomy or an ileostomy

Diverticulosis

• Saccular herniation of colon mucosa through the muscular wall of the colon• Result is an “outpouching”

of the intestinal wall. This pouch acts as a pocket in which digestive material can become caught and cause inflammation of the “pouch”

• Inflamed diverticula is called diverticulitis

Diverticulitis

Etiology – low roughage diet allows digested material to become trapped in pouches

Pathology – fluid is absorbed and the material becomes a concretion

• Concretion causes the diverticula to become inflamed which causes bowel obstruction, possible fistula formation, and if perforation occurs, peritonitis

Diverticulitis (cont.)

S & S: localized pain and tenderness, fever, leukocytosis, alternating constipation and diarrhea, possible hemorrhage, flatulence

Treatment:• High roughage diet and adequate fluid

intake to prevent concretion formation• Surgery to resect inflamed area

• May require ileostomy or colostomy

Neoplasia in the Stomach, Small and Large Intestine

Carcinoma of the Stomach• Etiology – unknown, but

chronic gastritis due to helicobacter infection may be a cause

• S & S – very vague but may be similar to an ulcer• Except gastric acidity is

usually normal or low and food intake does not usually ameliorate symptoms

• Often no specific symptoms until the cancer has metastasized

• Treatment: Surgical resection with chemotherapy

Polyposis• A mass of pedunculated

tissue seen in the colon• The bigger the polyp, the

more likely it is to be a pre-cancerous mass

• Primary symptom is rectal bleeding

• Treatment – removed during sigmoidoscopy/colonoscopy and tissue is biopsied• Resection of colon tissue if

malignant cells are seen

Colo-Rectal Cancer

• Usually a slow-growing adenocarcinoma• Second leading cancer

after lung

• Etiology• Heredity• High fat diet that is

low in fiber• Polyposis• Chronic ulcerative

colitis

Colo-Rectal Cancer (cont.)

S & S:

• Unexplained weight loss and fatigue

• Blood in stool (may be occult)

• Periods of constipation and diarrhea

Diagnosis: colonoscopy, sigmoidoscopy, and/or barium enema

Treatment: Surgical resection with chemotherapy• May end up with a colostomy

Hernia

Protrusion of an organ (or part of an organ) through the wall of the cavity

normally containing it

Inguinal Hernia – intestine protrudes through the abdominal

wall in the groin or in the scrotum

Inguinal Hernias (cont.)

• Etiology: congenital defect in fascia or damage due to straining

• Pathology:• Reducible – herniated tissue

can be pushed back into place

• Incarcerated – herniated tissue can not be pushed back into place

• Strangulated – incarcerated hernia has had its blood supply cut off and the tissue becomes necrotic

• S & S – minimal if any pain; just noticeable “bulge” where there should normally not be one

• Treatment: Surgical repair• Strangulated hernia is a

surgical emergency

Hiatal Hernia

• Herniation of the stomach into the thorax at the esophageal hiatus

• Etiology: congenital, age, trauma

• S & S: intense indigestion especially if patient goes to bed after eating

• Treatment: frequent small, meals; allow at least three hours before going to bed after a meal; sleep with head elevated; drug therapy

Umbilical Hernia

• Herniation of umbilical stump in young children

• Usually no complications and recedes on its own• Very stressful to the

parents!

Omphalocele

• Herniation of abdominal viscera due to congenital defect in abdominal wall closure in utero

• Surgical emergency

Malabsorption Syndrome

Failure to digest and/or absorb food

Etiology

Impaired digestion:

• Pancreatic disease

• Liver disease

• Altered continuity of the GI tract• Injury

• surgery

Impaired absorption:• Crohn’s disease• Ulcerative colitis• Celiac disease

• Gluten intolerance• Causes atrophy of intestinal

mucosa

• Tropical Sprue• Chronic inflammation and

atrophy possibly due to parasite, food toxin, or vitamin deficiency

Malabsorption Manifestations

• Weight loss

• Cutaneous bruising

• Abdominal distension

• Anemia

• Calcium deficiency

• Fat-soluble vitamins deficiency

• Large, bulky, foul smelling fecal material

Malabsorption Treatment

Depends on the specific cause:

• Celiac disease – gluten free diet

• Tropical Sprue – folic acid and tetracycline

• Treatment of underlying cause (pancreatic disease, liver disease, etc)

• Replacement of lost vitamins and minerals

Liver Disease

Hepatitis

Acute or chronic inflammation of the liver that causes poor liver function due to necrosis and the buildup of

fatty cells in the liver

Hepatitis Etiology

• Biliary tract dysfunction, eg, biliary atresia

• Substance abuse• Causes some necrosis and a lot of fatty

deposition

• Often leads to chronic inflammation which can cause cirrhosis and/or liver cancer

• Viral infection

Viral Agents

• Type A (also known as infectious hepatitis)• Freely shed in saliva and fecal matter

• Epidemics occur with contaminated food and water

• Type B (also known as serum hepatitis)• Found in blood and body fluids

• Spread through poor decontamination, sexual intercourse, etc

Viral Agents (cont.)

• Type C (also known as non-A, non-B)• Blood and body fluids

• Type D• Found only in patients already infected with type B

• Type E• Similar to A; poor hygiene and sanitation

• Type G• Blood and body fluids

Hepatitis Manifestations

Flu like symptoms

• Anorexia

• Malaise

• N & V

• Sometimes B, C, D, E and G will have no symptoms

• Large, palpable liver

• Dark urine

• Jaundice

• Labs• Decreased liver function

• Increased liver enzymes

• In severe cases of hepatitis, the patient may lapse into a coma

B, C, D E, or G may become chronic and or the patient may become a “carrier” of the disease

Hepatitis Treatment

• Primarily supportive• For known exposure to type A, gamma – globulin (up

to 14 days after exposure)

• Interferon for chronic B and C• Many experimental therapies

• Prevention• Proper hygiene and sanitation• Vaccines for prevention of type A and B

• Chronic hepatitis can lead to cirrhosis and/or liver cancer

Cirrhosis

End stage liver failure usually caused by chronic inflammation

(Biliary tract problems, substance abuse, chronic infection)

Cirrhosis Pathology

• Necrosis• Fibrosis• Nodular regeneration

• Often “fatty” nodules

• Fibrosis and nodular regeneration often lead to portal hypertension• This leads to

esophageal varices and splenomegaly

Cirrhosis Manifestations(due to poor liver function AND

portal hypertension)• Weakness, malaise,

anorexia and weight loss

• Hemorrhage/shock due to esophageal varices

• In males, hair loss, testicular atrophy, and gynecomastia

Cirrhosis Manifestations (cont.)• Ascites (due to

hypoproteinemia and portal hypertension)

• Jaundice

• Spider angioma and “Caput Medusae”

• Multi-organ system failure. Eg, renal failure, respiratory failure

• Encephalopathy/hepatic coma due to accumulation of nitrogen-containing compounds in blood

Hepatic Coma

Cirrhosis Treatment

• Surgical shunts to control esophageal varices and ascites

• Supportive care

• Liver transplant

Gallbladder Disease

Cholelithiasis

The presence of stones in the gallbladder

Cholelithiasis (cont.)

• Stones are usually a sediment from bile containing cholesterol, bilirubin, and calcium

Cholelithiasis Etiology

Cholelithiasis Diagnosis

• Abdominal X-ray

• Cholecystogram

• Ultrasound (usually best)

Cholelithiasis (cont.)

Stones cause obstruction of the biliary tract which can lead to:

• Cholecystitis

• Hepatitis

• Pancreatitis

Cholelithiasis Treatment

• Chenodiol• Helps dissolve stones so that they pass

• May take weeks or months to work

• Lithotripsy• Ultrasound to break up stones

• Cholecystectomy

Cholecystitis

Inflammation of the gallbladder usually caused by cholelithiasis

Cholecystitis (cont.)

• Gallbladder becomes swollen and the wall starts to ooze calcium

• This facilitates more stone formation

• Cholelithiasis causes cholecystitis and cholecystitis causes cholelithiasis!

Cholecystitis Manifestations

• RUQ pain• Rebound tenderness

• N & V

• Fever

• Bloating and belching

• Peritonitis if the gallbladder perforates

Cholecystitis Treatment

• Pain meds and hydration

• Cholecystectomy if repeated episodes or perforation occurs

• Treat cause of stone formation

Pancreatic Disease

Pancreatitis

Acute or chronic inflammation of the pancreas resulting in pancreatic

necrosis and possible hemorrhage

Pancreatitis Etiology

• Biliary tract disease• Usually from cholelithiasis and cholecystitis

• Alcoholism

Pancreatitis Pathology

• Etiologic agent causes an increase in pressure in the pancreatic ducts which allows pancreatic enzymes to be released into the pancreatic epithelium

• Besides poor pancreatic function, this can lead to necrosis of the pancreas and allow it to start hemorrhaging and may also result in perforation• Peritonitis!

Pancreatitis Manifestations

• Severe LUQ pain

• N & V

• Fever

• Signs of shock if hemorrhaging

• Signs of peritonitis if perforation occurs

• Labs show high levels of pancreatic enzymes in the blood

• If chronic, malabsorption and possibly diabetes

Pancreatitis Treatment

• Pain management• Opiates tried first but in some patients, this

intensifies the pain

• Anticholinergics to inhibit pancreatic enzyme secretion

• NPO and IV hydration

• May need surgery for necrosis or hemorrhaging

Diabetes Mellitus“Diabetes”

A syndrome characterized by abnormal insulin secretion and/or utilization, hyperglycemia, and

systemic complications caused by the abnormal insulin secretion/utilization

and hyperglycemia

Insulin

Allows glucose to enter cells for metabolism and allows excess blood glucose to enter the liver to be stored

as glycogen

Etiology

• Heredity

• Damage to the pancreas from either trauma or disease

• Autoimmune reaction (possibly triggered by viral infection

• Obesity

• Aging

Diabetes Types

• Type 1• Also know as Insulin Dependent Diabetes Mellitus

(IDDM) or juvenile onset

• Pancreas makes minimal or no insulin

• Type 2• Also known as Non-insulin Dependent Diabetes

Mellitus (NIDDM) or adult onset

• Pancreas doesn’t make quite enough insulin and/or cells have developed a resistance or tolerance to insulin

Diabetes Pathology

Diabetes ManifestationsType 1

Hyperglycemia• Glycosuria• Polyuria• Polydipsia• Polyphagia• N & V• Dehydration• Infections & wounds that

don’t heal• Warm, red, itchy skin

Ketosis (Ketoacidosis)• Unexplained weight

loss• Kussmaul respirations• Pungent, “fruity”

smell to breath• Metabolic acidosis• Appears intoxicated• Coma

Diabetes ManifestationsType 2

More gradual onset

• Hyperglycemia and glycosuria

• Polydipsia, polyuria, and polyphagia

• Unexplained weight loss

• Tingling sensations or hot sensation in lower leg and foot

• Infections and wounds that don’t heal

Diabetes Diagnosis

Besides manifestations:

• Elevated fasting blood sugar (FBS)• May also utilize Glucose tolerance Test (GTT)

• Glycosylated hemoglobin greater than 6% (A1C)• Best test to show long term blood glucose levels and

control

• UA to check for glycosuria, proteinuria, and ketonuria

Diabetes TreatmentType 1

• Diet – specific caloric intake for proteins, carbohydrates, and fat

• Exercise regime• Insulin injections

• Self-administered and requires frequent blood sugar monitoring

• Implanted insulin pump• Transplant (pancreatic cells or stem cells)

Diabetes TreatmentType 2

• Diet – low fat diet and no more than 50% carbohydrate• Weight loss too!

• Exercise• Helps lower blood sugar and to sensitize the body’s cells

to insulin

• Oral drugs• Hypoglycemic drugs (sulfonylureas) such as Diabinase,

Tolinase• Insulin sensitizing drugs (also slow the release of glucose

from the liver) - Glucophage

Diabetes Complications

• Occur more quickly and severely in Type 1

• Are due to swings in blood sugar levels and increased lipid metabolization which damages the basement membrane of the blood vessels

Diabetes Complications (cont.)

• Atherosclerosis • More prone to heart attack and stroke

• Hyperglycemia – gradual development of original symptoms• Usually patient eats too much or does not take medications

• Hypoglycemia –comes on quickly!• Patient is not eating enough or is taking too much

medication• Personality change, headache, jittery/tremors, profuse

sweating, seizure• This patient needs sugar!

Diabetes Complications (cont.)Retinopathy

• Due to blood vessel damage, diabetics are prone to retinal artery aneurysm, hemorrhage, and detachment. • Partial or total vision

loss

• Also increased chance of cataracts

Diabetic Complications (cont.)Nephropathy

• Due to poor blood flow and hyperglycemia, diabetics are prone to repeated bouts of pyelonephritis• May become chronic

• This could progress to chronic renal failure

Diabetic Complications (cont.)Neuropathy

• Poor blood flow and hyperglycemia tend to cause nervous system dysfunction

• Ankle and wrist drop

• Tingling, pain, and a sensation of heat in the lower leg and feet

• Strabismus and diplopia

Diabetic Complications (cont.)Poor Wound Healing

• Because of poor blood flow, hyperglycemia, and poor nervous system function, diabetics are prone to wounds on the lower extremity that get infected and don’t heal• Gangrene infection is

the worst

With a good care and monitoring plan, and a compliant patient,

the frequency and severity of these complications can be diminished