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INTESTINE
DIAREEA
Definition >3 feces/day, > 200 g/day
Physiology:
– in gastrointestinal tract 9-10 l fluids (2l ingestion, the rest
secretions);
– Na - co-transport with Cl and glucose in small bowel and biliary
salts in terminal ileum; co-transport with H - HCO3; K absorbed with
H or Ca.
– In colon, Na absorbed through apical membrane canals
– parasimpatic is stimulating the peristalsis and electrolyte secretion;
simpatic nerves are doing the opposite.
– Enteric nervous system.
Figure 4.1 - Water fluxes through the intestine
Postresection diarrhea
Short-bowel syndrom e
Celiac disease
Crohn`s disease
Lymphoma
Congenital chloridorrhea
Bacterial toxins
Cholera
Shigella
Staphylococcus
Clostridium perfringens
Luminal secretagogues
Bile acids
Circulating secretagogues
Glucagon (glucagonoma)
Puborectalis electromyography
Anorectal angle
Perineal descent
Retention of contrast
•History taking
•Physical examination
•Diagnostic techniques
•History taking
•Check for age of onset ( sudden or long term)
•Check for ROME- II criteria
•Check for neurological disorders
•Check for psychiatric conditions
•Check for family history of constipation?
•Physical examination
•Palpation of abdomen ( tumour )
•Percussion ( check for gases)
•Rectal palpation
•Consistency/impaction
•Presence of non-fecal masses or abnormalities (tumors, hemorrhoid,
fissures)
•Presence of blood
•Sphincter tone
•Diagnostic techniques
•Stool analysis
•Weighing 3 days; < 100g avg means constipation
•Abdominal x-rays
•Abdominal echography
• Tumour mass
•Anorectal function tests
•Manometry
•Electromyography
•Rectal mucosal biopsy
•Colonic transit time (radiopaque marker)
Major alarm symptoms especially in patients >50yrs
Ulcerative colitis
Crohn’s disease
2
40
30
Prevalence
(per 105)
20
10
0
White Black Hispanic Asian Other
and sex
pathogenesis of IBD
Genetics
Mycobacterium paratuberculosis
Measles virus
30
Genetic factors
It is estimated that between 10 and 20 genes
are involved
Susceptibility loci have been located on
chromosomes 3, 7, 12 and 16
The genetic contribution to the aetiology of
both Crohn’s disease and ulcerative colitis
is polygenic NOT Mendelian
Pathological and anatomical features 23
ulcerative colitis
Bloody diarrhoea
Fever
Cramping abdominal pain
Weight loss
Frequency and urgency of defecation
Tenesmus
General malaise
Investigation
Colonoscopy
3
ulcerative colitis
Fibrosis
Shortening of the colon
Bleeding
Stricture
Bowel perforation
Toxic megacolon
Systemic complications of
8
ulcerative colitis
Arthritis
Iritis
Erythema nodosum
Pyoderma gangrenosum
Sclerosing cholangitis
Aphthous stomatitis
Thromboembolic disorders
9
during pregnancy
15
Relapse in
pregnant 10
women with
UC, who were
remission at
5
conception
(%)
0
1st 2nd 3rd Post-partum
(Forbes, 1997)
Clinical presentation of Crohn’s
21
disease
Diarrhoea
Abdominal pain
Bleeding
Pyrexia
Weight loss
Fistulae
Perianal disease
General malaise
Investigation
Colonoscopy
13
Crohn’s disease
Fistulae
Abscesses
Adhesions
Strictures
Obstruction
17
Crohn’s disease
Arthritis
Gallstones
Malabsorption
– Lactase deficiency
– Vitamin B12 deficiency
Renal stone formation
22
– Fourth malignant
localization after lungs,
stomach and breasts.
– 1023 000 new annual
cases and 529.000
deaths
– 10% of total deaths due
to cancer in developing
countries.
Europe in 2000
highest increased
incidents 300.000
new cases
Czech Republic,
Hungary, Slovakia,
Germany have
incidents much
higher ( 2x than
USA in general)
Net increase in the tendency of colorectal cancer (all statistic
reports).
Increase in colorectal cancer incidents with proximal localization
1000000
500000
0
1975 1990 1996 2003
with 4016 deaths in 2002 (OMS report) Romania registered a
mortality rate of 11,3/100 000.
For both localizations levels of mortality presented an intentional
increase of constancy and continuity, with a higher increased rate for
colon cancer.
In the last 40 years mortality doubled, an important increase in
comparison with other European countries.
12
10
6
Mortalitate
4
0
1969 1975 1996 2002
Territorial distribution of mortality levels (standardized indicators) for
colon and rectal cancer.
The study which took place between 1994-1996 using data acquired
from city hospitals from Moldova revealed a higher level of mortality
for colon cancer for cities Neamţ ,Galaţi, Botoşani.
IRITABLE BOWEL SYNDROME
Functional
gastrointestinal
disorders - a
frequent cause for
referral to
gastroenterologist
Epidemiology
Additional investigations
– Colonoscopy or double contrast barium enema (>45 ani)
– coproculture
– Occult blood loss
Colon spastic
Diarrhea
– Diarrhea is the most common symptomatic complaint.
– Diarrhea frequently is watery, reflecting the osmotic load received
by the intestine.
– Bacterial action producing hydroxy fatty acids from undigested fat
also can increase net fluid secretion from the intestine, further
worsening the diarrhea.
Steatorrhea
– Steatorrhea is the result of fat malabsorption.
– The hallmark of steatorrhea is the passage of pale, bulky, and
malodorous stools.
– Such stools often float on top of the toilet water and are difficult to
flush. Also, patients find floating oil droplets in the toilet
following defecation.
Weight loss and fatigue
– Weight loss is common and may be pronounced; however, patients
may compensate by increasing their caloric consumption, masking
weight loss from malabsorption.
– The chance of weight loss increases in diffuse diseases involving
the intestine, such as celiac disease and Whipple disease.
Flatulence and abdominal distension
– Bacterial fermentation of unabsorbed food substances releases
gaseous products, such as hydrogen and methane, causing
flatulence.
– Flatulence often causes uncomfortable abdominal distention and
cramps.
Edema
– Hypoalbuminemia from chronic protein malabsorption or from
loss of protein into the intestinal lumen causes peripheral edema.
– Extensive obstruction of the lymphatic system, as seen in intestinal
lymphangiectasia, can cause protein loss.
– With severe protein depletion, ascites may develop.
Anemia
– Depending on the cause, anemia resulting from malabsorption can
be either microcytic (iron deficiency) or macrocytic (vitamin B-12
deficiency).
– Iron deficiency anemia often is a manifestation of celiac disease.
– Ileal involvement in Crohn disease or ileal resection can cause
megaloblastic anemia due to vitamin B-12 deficiency.
Bleeding disorders
– Bleeding usually is a consequence of vitamin K malabsorption and
subsequent hypoprothrombinemia.
– Ecchymosis usually is the manifesting symptom, although
occasionally, melena and hematuria occur.
Metabolic defects of bones
– Vitamin D deficiency can cause bone disorders such as osteopenia
or osteomalacia.
– Bone pain and pathological fractures may be observed.
– Malabsorption of calcium can lead to secondary
hyperparathyroidism.
Neurological manifestations
– Electrolyte disturbances such as hypocalcemia and
hypomagnesemia can lead to tetany, manifesting as the Trousseau
sign and the Chvostek sign.
– Vitamin malabsorption can cause generalized motor weakness
(pantothenic acid, vitamin D) or peripheral neuropathy (thiamine),
a sense of loss for vibration and position (cobalamin), night
blindness (vitamin A), and seizures (biotin).
Physical findings:
General
– Patients may have orthostatic hypotension.
– Fatigue
– Signs of weight loss, muscle wasting, or both may be present.
– Patients may have signs of loss of subcutaneous fat.
Abdominal examination
– The abdomen may be distended, and bowel sounds may be
hyperactive.
– Ascites may be present in severe hypoproteinemia.
Dermatological manifestations
– Pale skin may reveal anemia.
– Ecchymosis due to vitamin K deficiency may be
present.
– Dermatitis herpetiformis, erythema nodosum, and
pyoderma gangrenosum may be present.
– Pellagra, alopecia, or seborrheic dermatitis
Neurological examination
– Motor weakness, peripheral neuropathy, or ataxia may
be present.
– The Chvostek or Trousseau sign may be evident due to
hypocalcemia or hypomagnesemia.
Cheilosis, glossitis, or aphthous ulcers of the
mouth
Peripheral edema
TABLE 5-33. SELECTED SYMPTOMS AND SIGNS OF NUTRIENT DEFICIENCIES
Symptoms or sign Possible nutrient deficiency
Weakness, weight loss, muscle
Protein, calorie
wasting
Pallor Folate, iron, vitamin B12
Follicular hyperkeratosis Vitamin A, vitamin C
Perifollicular petechiae Vitamin C
Protein, calorie, niacin, riboflavin, zinc,
Dermatitis
vitamin A, essential fatty acids
Bruising, purpura
Easily plucked, alopecia Vitamin C, vitamin K
Corkscrew hairs, coiled hair Protein, zinc, biotin
0-50 - TPN
+ TPN
51-100 - IVFM/TPN
+ Regular diet
+ Regular diet