GIT Dr. Osama Mahmoud.pdf

LECTURE NOTES OF INTERNAL MEDICINE

Gastroenterology Biliary system Pancreas

Dr. Osama Mahmoud Mohamed Assistant Professor of Internal Medicine Ain Shams University

Inlea • DislJaslJs ollhlJ Mouth

1

Stomatitis

• DislJaslJs ollhlJ 10ngulJ • DislJaslJs ollhlJ Salivary Glands • DislJaslJs ollsophagus

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3 4

5

Structure of the esophagus

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Hiatus Hamia

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Esophageal Achalasia

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Carcinoma of the Esophagus

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Gastro-Esophageal Reflux Disease (GERD)

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9

Miscellaneous disorders of the esophagus

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• DislJaslJs olthlJ Stomach and DuodlJnum

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Anatomy of the stomach & duodenum

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Peptic Ulcer -

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Pharmacology of drugs used in peptic ulcer

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20

Acute Gastritis, Erosions & Acute Ulcerations

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22

Chronic Gastritis

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23

Cancer Stomach

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23

Miscellaneous disorders of the stomach & duodenum

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25

• DiSIJ8SIJS ollntlJstinlJ Malabsorption Syndrome (Intestinal Failure)

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28 28

Dysentery

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Intestinal Amoebiasis

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34

Bacillary Dysentery (Shigellosis)

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Intestinal Bilharziasis

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36

Inflammatory Bowel disease

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37

Functional bowel disorders

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42

Megacolon

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Cancer Colon

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Diverticular Disease of the Colon

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45

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Familial Adenomatous

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Neuroendocrine

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Carcinoid Tumours

48

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Intestinal Obstruction

49

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Acute Appendicitis, Meckel's Diverticulum

51

• GallB/adder

Polyposis

Tumors of the Gastrointestinal

& BillialY

. Tract Pancreas

System.......................................................................................

46 47

52

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Gall Stones

52

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Acute Cholecystitis

54

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Chronic Calculous Cholecystitis

55

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Miscellaneous

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diseases of the biliary system

• ThlJ Pancreas..............................................................

58

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Acute Pancreatitis

59

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Chronic Pancreatitis

62

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Carcinoma of the Pancreas

63

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Pancreatic islet tumors

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• Acute Abdomen.......................................................................................................... • Protein losing loterBPathy........ • MotililY disorders of GIl................. . .. . • GIlBleeding.................... .. • Diseases of Peritoneum...................................................... .

65 67 67

67 68

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Acute Peritonitis

68

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Tuberculous Peritonitis

68

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Malignant Ascities and Tumors of Peritoneum

70

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Retroperitoneal

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fibrosis........................................................................

• Functional Gastrointestinal Disorders................................................................ • GITinvolvement in systemic diseases........... • Extra-gastrointestinal 01 multi system manifestations of G/ldisorders................................................... .. • Systemic manifestations of pancreatic diseases...... • Immune mediated GIl diseases..........................................

71 71

72 72 72

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~1D.isjases'~ol·'lhe~~MOUlh 1,,0InealII:ISI -

The mouth contains many of commensal micro organisms. So, oral hygiene is essential. Negligence of oral hygiene may lead to bacterial proliferation causing stomatitis.

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Stomatitis may also occur when resistance to the commensal population is lowered e.g. in the immune-compromised host.

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Stomatitis may also occur due to nutritional deficiency.

1- Ulcll'allvl

510111alilis (Vlllcllll'S IllflClloll)

Clinical Picture -

It occurs in adults with malnutrition and poor dental hygiene.

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There are ulcers on the gum, palate, lips and the inner aspects of cheeks.

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Halitosis.

Investigations -

A stained smear shows spirochetes and fusiform bacilli.

Treatment -

Metronidazole or penicillin.

2- VII'al 510111alilis -

Herpes simplex may cause herpes labial is in normal persons.

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It can lead to severe stomatitis in immune-compromised

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Coxsackie virus causes herpangina with acute pharyngitis, ulcers of the soft palate and pharyngeal mucosa.

patients.

3- Calldldlasls (Mollillasls) Etiology -

The fungus candida albicans is a normal commensal in the mouth. It may proliferate to cause thrush in babies and in debilitated patients. Also thrush is common in patients receiving prolonged treatment with antibiotics and in patients who are immunosuppressed by corticosteroids or AIDs.

1

GIT

Clinical picture -

White patches on the tongue and buccal mucosa. In severe infection the pharynx and esophagus can be affected causing dysphagia.

Treatment -

Cause. Lozenges or suspension of nystatin. Systemic antifungal in severe infection.

4· 5tOll18tltis dlle to 1111tl'lt101181dellclellCY -

This occurs due to deficiency of niacin, riboflavin, folic acid and vitamin B12.

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When the deficiency is acute and severe the tongue is red and painful because of atrophy of the papillae.

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Angular stomatitis often accompanies glossitis especially in severe riboflavin and iron deficiency.

-kA~g~.~!r._~b~Ii~~.~. (angular.stom~ti.is) It is erythema or crusting of the labial angles.is a/so caused by candida. It is associated with.intraoral candidasis. It is treated with topical with or without systemic. antifungal drugs, iron and vitamin supplements.

* ~_b.~Ul~J~. Painful vertical fissures mainly of lower lip caused by malnutrition. It may occur in crohn's disease or with·exposure to sunlight and wind.

5- ReCIII'I'ellt 8plltll01.S

IllcCI'8t1011

Etiology (Mfecting 20% of the population) -

Unknown etiology. Emotional stress may precipitate the attack. May occur during the premenstrual phase. May occur in association with Crohn's disease, ulcerative colitis or Behcet's disease. Nutritional deficiencies with or without GI disorders are occasionally found. The ulcers are recurrent at intervals of days to a few months.

Clinical picture -

painful. Multiple shallow rounded ulcers, theyyare p

*

Minor ophthous ulcers are < 10mm with grey white centre with thin erythematous halo and heal with 14 days without scarring, * Major aphthous ulcers > 10mm persist for weeks or months and heal with scarrmg.

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Treatment -

Hydrocortisone hemisuccinate lozenges. To ical anesthetics.

- Colchicine

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Erythema multiforme (Stevens Johnson $). Lichen planus. - Pemphigus vulgaris .

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'.: ;:0. - Antimalarials. / ," ,'," '- ,"Penicillamine and gold salts.

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. Inflammatory bowel disease. .: . ;.~::: : SLE.

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It is a squamous cell carcinoma. Tobacco, alcohol consumption factors. Treated by surgical excision and/or radiotherapy.

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Acute necrotizing gingivitis (Vincent's gingivitis). Gingival swelling or hypertrophy may occur due to hereditary gingival fibromatosis, drugs (phenytoin, cyclosporine and nifidipine), re nanc ,scu and acute leukemia. .

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Glossitis: • •

It may be involved in stomatitis due to nutritional deficiency. Glossitis is a red, smooth, sore tongue seen in 812, folate and iron deficiency.

Leukoplakia: • • • • • •

It is a chronic lesion (White, firm smooth patches). It usually starts at the side of the tongue. Early it is not painful but later become tender. It is associated with alcohol and smoking. It may precede the development of carcinoma. Isotretinoin may reduce disease progression.

Black hairy tongue: (unknown etiology) It is due to proliferation of chromogenic staining of elongated filiform papillae.

microorganisms

causing brown

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Functional disorders: •

Glossodynia (painful tongue) and glossopyrosis (burning sensation in the tongue) if the tongue looks normal the cause may be depression.

•

Bad taste in the mouth is sometimes due to drugs or sinusitis but it may reflect anxiety or depression.

Tumors of the tongue -

Squamous cell carcinoma.

- Kaposi's sarcoma in AIDs.

QIJeaSe$Df\the~SalillaI!lGlands PlYallslll (IXCIsslvI sallvatloll) Causes 1- Psychogenic. 2- Prior to vomiting. 2- Secondary to oral pathology e.g. stomatitis.

XII'oStolllla (dl'YIIISS of tile 111011tll) -

Dehydration. - Psychogenic. Sjogren's $. - Radiotherapy. Drugs e.g. anticholinergics and antihistaminics.

Sialadeilltis

(1II'lalll.118tI011of sallval'l' glallds)

Acute sialadenitis may be due to mumps (parotitis) or bacteria.

Sallval'l' calcllll These occur occasionally in the submandibular gland or its ducts.

Clinical picture -

Painful swelling of the submandibular gland after eating. Stones can sometimes be felt in the floor of the mouth.

Invsestigations -

Sialography.

- Plain X-ray will show the stone.

Treatment -

Surgical removal.

"IODlaSlll 0' sallval'l' glallds -

The majority occur in the parotid gland. The pleomorphic adenoma is the commonest which may turn malignant. Malignant tumors usually result in lower motor neurone lesion of facial nerve.

Sarcoidosis can involve salivary gland. e.g. in cases of Heerfordt's and Mikulicz svndromes (see chest dieeesee). 4

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It is a hallow muscular tube, about 25 cm long connecting the pharynx to the stomach, it has no significant absorption or secretory function.

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It is lined by stratified squamous epithelium except near the gastroesophageal junction lined by columnar epithelium.

• The esophagus is separated from the pharynx by the upper esophageal sphincter (UES) which is normally closed by the cricopharyngeus muscle contraction. • The lower esophageal sphincter (LOS) consists of an area of the distal end of the esophagus with a high resting tone to prevent reflux. • The relaxation and reduction of LOS tone that occurs during swallowing is under the control of vagus and other hormonal mechanisms. The presynaptic neurotransmitter is acetylcholine. The postsynaptic neurotransmitters which cause relaxation are nitric oxide and vasoactive intestinal peptide. •

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