17. gastroenterology
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Gastrointestinal Gastrointestinal DiseaseDisease
Normal AnatomyNormal Anatomy
and and
PhysiologyPhysiology
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Gastrointestinal Gastrointestinal Disease:Disease: ObjectivesObjectives
1. To increase students’ working 1. To increase students’ working knowledge of gastrointestinal knowledge of gastrointestinal anatomy, physiology and pathologyanatomy, physiology and pathology
2. To incorporate this working 2. To incorporate this working knowledge into patient assessment knowledge into patient assessment and clinical decision makingand clinical decision making
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GastrointestinalTract:Pharynx
Esophagus
Liver
Stomach
Duodenum
Small bowel
Large bowel (colon)
Rectum
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GI: DisordersGI: Disorders
Gastro Esophageal Reflux Disease (GERD)
Peptic Ulcer Disease (PUD)
Inflammatory Bowel Disease (IBD)
Pseudomembranous colitis
Irritable Bowel Syndrome (IBS)
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Gastro Esophageal Reflux Disease (GERD)
Gastro esophageal junction
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GI: Disorders: GERDGI: Disorders: GERD
Gastro Esophageal Reflux Disease (GERD)
Problem: reflux of acidic gastric contents into the esophagus
Often related to hiatus hernia
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GI: Disorders: GERDGI: Disorders: GERD
Complications:
ulceration
stricture
bleeding
Fe deficiency anemia (20 to bleeding)
aspiration
Barrett’s epithelium: increased risk of
esophageal cancer
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GI: Disorders: GERDGI: Disorders: GERD
Symptoms
Typical: heartburn (pain)
Atypical: cough, asthma, hoarseness,
chest pain, aphthous ulcers,
hiccups, dental erosions
Warning (of stricture): dysphagia, early
satiety, weight loss, bleeding
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GI: Disorders: GERDGI: Disorders: GERD
Diagnosis
Symptoms
Endoscopy
Response to Proton Pump Inhibitor
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GI: Disorders: GERDGI: Disorders: GERD
Treatment: Lifestyle modification
Diet, meal timing, HOB up 6 inches
Decrease: fat, cola, chocolate, coffee, alcohol, smoking
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GI: Disorders: GERDGI: Disorders: GERD
Treatment: Drugs
Antacids: Tums, Rolaids
H2 blockers: raniditine, cimetidine, famotidine
Proton pump inhibitors: omeprazole,
lansoprazole
Prokinetic agents: bethanechol, metoclopramide, domperidone
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GI: Disorders: GERDGI: Disorders: GERD
Dental Considerations:
Be aware of worsening symptoms
Risk of aspriation with positioning or
sedation
Dental changes due to oral acid reflux
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Peptic Ulcer Disease (PUD)
Stomach
Duodenum
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GI: Disorders (PUD)GI: Disorders (PUD)
Peptic Ulcer Disease (PUD)
- 3 mm or greater break in the mucosa
- 80% duodenal / 20% gastric
- 10% have multiple ulcers
- prevalence 5 - 10% of population
- 100 patients in a 2000 patient population
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GI: Disorders (PUD)GI: Disorders (PUD)
Peptic Ulcer Disease: Etiology
- Helicobacter pylori
- found in 20% of adults > age 20 in NA
80% in developing countries
- approx 20% of infected individuals
go on to having PUD
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GI: Disorders (PUD)GI: Disorders (PUD)
Peptic Ulcer Disease: Etiology
- Helicobacter pylori (70-90%)
- acid hypersecretion
- cigarette smoking / alcohol
- NSAID use (15-20%)
- psychological and physical stress
- age 30 - 50
- steroid use
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GI: Disorders (PUD)GI: Disorders (PUD)
Peptic Ulcer Disease: Pathophysiology
- Helicobacter pylori produces urease
which converts urea to NH3 and CO2
- this initiates an inflammatory cascade
which causes mucosal breakdown
often in association with co-factors
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GI: Disorders (PUD)GI: Disorders (PUD)
Peptic Ulcer Disease: Complications
- Hemorrhage … worse if anti-coagulated
- Perforation … peritonitis
- Scarring … pyloric stenosis
- Malignant transformation: carcinoma or lymphoma
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GI: Disorders (PUD)GI: Disorders (PUD)
Peptic Ulcer Disease: S & S
- Pain
- Relief by antacids, milk or food
- Melena (blood in stool) due to bleeding
- Worsening of symptoms may indicate
complications such as perforation or
pyloric outlet obstruction
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GI: Disorders (PUD)GI: Disorders (PUD)
Peptic Ulcer Disease: Diagnosis
- Signs and Symtoms
- Urea breath test 13C (office) or 14C (lab)
for Dx and response to Tx
- Double contrast barium radiograph
- Fibreoptic endoscopy:
visualization and biopsy
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GI: Disorders (PUD)GI: Disorders (PUD)Peptic Ulcer Disease: Treatment
Without H. pylori: antisecretory drugs
H2 antagonists: cimetidine (Tagamet)
ranitidine (Zantac)
famotidine (Pepcid)
Proton pump inhibitors: omeprazole (Prilosec)
(PPIs) lansoproazole (Prevacid)
esomeprazole (Nexium)
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GI: Disorders (PUD)GI: Disorders (PUD)Peptic Ulcer Disease: Treatment
With H. pylori: antibiotics and antisecretory drugs
Antibiotics: tetracycline and metronidazole
amoxicillin and clarithromycin
Proton pump inhibitors: omeprazole (Prilosec)
(PPIs) lansoproazole (Prevacid)
esomeprazole (Nexium)
Bismuth subsalicylate (Pepto-Bismol)
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GI: Disorders (PUD)GI: Disorders (PUD)Peptic Ulcer Disease: Treatment results
With triple or quadruple drug therapy: 92 to 99%
success in eradicating H. pylori and curing ulcer
Failure typically due to:
- noncompliance with drug therapy
- continued use of NSAIDs, alcohol, smoking
- continued ingestion of spicy foods
- continued stressful lifestyle
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GI: Disorders (PUD)GI: Disorders (PUD)
Peptic Ulcer Disease: Dental concerns
- Be alert to signs and symptoms: refer
- Role of cyclo-oxygenase-2 (COX-2)
inhibitors?…details to follow
- Use acetaminophen preparations
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GI: Disorders (PUD)GI: Disorders (PUD)
Peptic Ulcer Disease: Dental concerns
- Use NSAIDs with caution or with PPIs
or misoprostol (Cytotec)
- Avoid NSAIDs if:
patient over 75
history of bleeding
concomitant steroid use
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Inflammatory Bowel Disease (IBD)
Crohn’s Disease:Distal ileum and proximal colon
Ulcerative Colitis:Distal colon and rectum
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GI: DisordersGI: Disorders
Inflammatory Bowel Disease (IBD)
Ulcerative Colitis and Crohn’s Disease
- Idiopathic (??? Genetic + environment)- Age of onset: 20 to 40- 5 patients in a 2000 patient practice
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GI: Disorders: IBDGI: Disorders: IBDFindings
Ulcerative Colitis Crohn’s Disease
- Limited to large intestine - Any portion of GI tract
(rectum-colon) (lips to anus)
- Limited to mucosa - Transmural
- Continuous - Segmental
- Episodic - Episodic
- Diarrhea - Diarrhea
- Bleeding, cramping - Pain LRQ, fever, wt loss
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GI: Disorders: IBDGI: Disorders: IBDComplications
Ulcerative Colitis Crohn’s Disease
- Anemia, malabsorbtion - Anemia, malabsorbtion
- Toxic megacolon - Fistulae, stricture
- Malignant transformation - Surgery more likely
more likely
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GI: Disorders: IBDGI: Disorders: IBD
Treatment
1. Supportive therapy: rest, fluids, lytes,
nutritional supplementation
2. Antiinflammatories: sulphaslazine,
5-ASA, corticosteroids
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GI: Disorders: IBDGI: Disorders: IBD
Treatment
3. Immunosuppressives: methotrexate,
cyclosporin,
4. Antibiotics: Flagyl / Cipro
5. Surgery
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GI: Disorders: IBDGI: Disorders: IBD
Dental Concerns
1. Potential for adrenocortical
suppression with steroids
2. Methotrexate: pneumonia, marrow
suppression, hepatic fibrosis
Cyclosporin: renal damage
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GI: Disorders: IBDGI: Disorders: IBD
Dental Concerns
3. Use acetaminophen / Avoid NSAIDs
4. Use Narcotics with caution
5. Opportunistic infections / lymphoma due to immuno-suppression
6. Crohn’s disease can manifest orally
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PseudomembranousColitis
Distal colon
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GI: DisordersGI: Disorders
Pseudomembranous colitis
Broad spectrum antibiotics cause loss of
enteric bacteria leading to an overgrowth
of Clostridium difficile which produce
enterotoxins that induce potentially fatal
colitis and diarrhea
commensal in 2-3% of adults / 50% of elderly
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GI: DisordersGI: Disorders
Pseudomembranous colitis
Clindamycin: 2 to 20%
Ampicillin/amoxicillin: 5 to 9%
Cephalosporins: < 2%
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GI: DisordersGI: Disorders
Pseudomembranous colitis
Signs and symptoms:
typically develop in 4 to 10 days
profuse, watery diarrhea
bloody diarrhea, fever, abdo pain
death
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GI: DisordersGI: Disorders
Pseudomembranous colitis
Diagnosis: enterotoxin found in stool
Treatment: d/c offending antibiotic
give PO Flagyl or Vancomycin
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GI: DisordersGI: Disorders
Pseudomembranous colitis
Dental consideration:
be cautious with the use of antibiotics
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Irritable Bowel Syndrome (IBS)
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GI: DisordersGI: Disorders
Irritable Bowel Syndrome (IBS)
Most common GI problem: functional
Idiopathic … psycho-social issues
Diarrhea, constipation, bloating, abdo pain
Difficult to control: dietary change, stress
management, antidepressants
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Questions????