GIT Dr.

Shaf3y

G.I.T. 6 2013 inflammatory bowel disease 18

Inflammatory Bowel Disease

Inflammatory bowel disease Inflammatory bowel disease

etiology inflammatory bowel disease etiology Actually, two diseases Ulcerative colitis regional ileitis Crohns two diseases unknown << cause theories drugs manifestations Increase Non steroidal actually non steroidal etiology exacerbation

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GIT Dr. Shaf3y

genetics genetics high incidence family history HLA B27 High association genetic element

allergy to certain types of food

Industrial countries More common << disease tropical countries common

Infection has been isolated << organism No organism has been isolated

More common affected 30 20

disease females

Smoking Protective against ulcerative colitis Smoking is protective against ulcerative colitis

incidence of Crohns disease smoking protective against ulcerative colitis incidence of crohns disease House ulcerative colitis
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GIT Dr. Shaf3y

this is the first time I have seen a doctor advise by smoking this is the only case in the whole world that the smoking is the treatment Ulcerative colitis

ulcerative colitis pathology ulcerative colitis pathology ulcerative colitis pathology Ulcerative colitis disease gross pictures rectum rectum

rectum

rectum ulcerative colitis bleeding

rectum

sigmoid colon << rectum whole colon << rectum terminal ileum whole colon << rectum rectum sigmoid colon colon

terminal ileum

continuous skip lesions transverse sigmoid

lesion

transverse

rectum rectum ascending colon

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GIT Dr. Shaf3y

transverse rectum continuous Lesion skip lesion site affected Mucosa Only << Mucosa as regard

colon inflammation ulcerative colitis

mucosa inflammation heal by fibrosis inflammation ulceration Inflammation fibrosis heal

loss of haustrations

fibrosis haustration

fibrosis

<<

fibrosis healing heal colon loss of haustration colon ulcerative colitis shortened colon

fibrosis damage area what we call polyps

damage mucosa islands of normal cells proliferate proliferate Normal pseudo polyps

fibrosis Loss of haustration

inflammation fibrosis colon shortening

fibrosis

areas

remnant proliferation pseudo polyps

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GIT Dr. Shaf3y

pre cancerous << Proliferating pre cancerous << proliferating pseudo polyps

gross pictures microscopic pictures microscopic pictures only << inflammation limited to the mucosa infiltrated by inflammatory cells << Mucosa lymphocytes leucocytes With the inflammation limited to mucosa clinical pictures ulcerative colitis dysentery Colics, diarrhea, tenesmus, blood and mucous in the stool dysentery

attacks of dysentery remission and exacerbation dysentery remission and exacerbation attacks exacerbation Non steroidal anti inflammatory drugs emotions stress extra intestinal manifestations Ulcerative colitis ulcerative colitis extra intestinal manifestations attacks

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GIT Dr. Shaf3y

Interstitial lung fibrosis interstitial lung fibrosis heart general constitutional manifestations anemia

abdomen auto immune hepatitis Liver High incidence of cholangio carcinoma sclerosing cholangitis cholecystitis gall bladder Kidney oxlate stones kidney erythema nodusum pyoderma gangrenosum skin ankylosing spondylitis joints rheumatology Inflammatory bowel disease ankylosing spondylitis pictures manifestations ankle Knee arthritis G.I.T. manifestations Inflammatory bowel disease

G.I.T.

exacerbation exacerbation

arthritis remission remission

rheumatology

intestinal manifestations complications inflammatory bowel disease complications Perforation Hemorrhage toxic megacolon cancer toxic megacolon paralytic ileus toxic megacolon small intestine paralytic ileus Large intestine toxic megacolon absolute constipation

disease
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GIT Dr. Shaf3y

dysentery infection Investigations investigations investigations stool analysis stool analysis << dysentery blood mucous bacillary amoeba stool analysis Infective etiology exclude

inflammatory bowel disease

anemia

CBC leucocytosis

cancer

biopsy Barium loss of hasturation

investigations Colonoscopy inflammation Mucosa Barium lead pipe appearance shorten bowel pseudo polyps << Polyps Liver function test auto immune hepatitis spine X ray ankylosing spondylitis

Polyps

treatment in between

treatment treatment during the attack treatment during the attack Steroids steroids steroids

Oral
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GIT Dr. Shaf3y

60 Oral dose dysentery intravenous Intravenous intravenous enema corticosteroid enema corticosteroid enema enema Limited to mucosa << inflammation enema mucosa contact << cortisone Mucosa Mucosa contact << enema Mucosa inflammation Oral IV fulminant colitis severe manifestations enema

toxic megacolon

fulminant colitis

systemic side effects

5 aminosalicyclic acid 5 aminosalicyclic acid acetylsalicyclic acid aspirin 5 aminosalicyclic acid anti inflammatory sulphanoamide orally sulphonamide 5 aminosalicyclic acid carrier sulphonamide sulphasalazine

aspirin

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GIT Dr. Shaf3y

sulphasalazine sulphonamide side effects

5 aminosalicyclic acid sulphonamide

orally

aminosalicyclic acid sulphonamide

during the attack anti diarrheal agents antispasmodic Symptomatic treatment

In between the attack cortisone sulphasalazine

In between attacks attacks sulphasalazine cortisone recent corticosteroids aminosalicyclic acid immune suppressant cyclosporine cyclophosphamide Azathioprine aminosalicyclic acid corticosteroids

cyclosporine

other immune suppressant cyclophosphamide Azathioprine

inflixmab
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tumor necrosis factors alpha inhibitor

GIT Dr. Shaf3y

failed medical treatment

And finally Surgical treatment surgery failed medical treatment fulminant colitis total coloectomy

total coloectomy malignancy

fulminant colitis

failed medical treatment complications surgical treatment fulminant colitis

high risk of cancer complications

Total coloectomy Terminal ileostomy

Mucosa

rectum terminal ileum Hartmann cuff cuff of muscles

mucosa

Ulcerative colitis

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Ulcerative colitis

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GIT Dr. Shaf3y

Cronhns Disease ( Regional enteritis )

Regional ileitis Crohns disease regional ileitis Inflammatory bowel disease anus Oral cavity

terminal ileum regional ileitis terminal ileum terminal ileum right sided colon Jejunum

right sided colon

patchy transverse colon terminal ileum

Legions << skip

sigmoid

terminal ileum

skip lesions affection skip patches gross pictures affected area gross pictures submucosa Mucosa inflammation the whole thickness inflammation the whole thickness limited to the mucosa only the whole thickness Inflammation
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serosa

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GIT Dr. Shaf3y

granulomatous Inflammation caseation Granulomatous lesions caseation mucosa fissured mucosa

cobblestone arrangement cobblestones

cobblestone arrangement the whole thickness the whole thickness inflammation Inflammation

Intestine

Perforation

the whole thickness inflammation intestine perforation regional ileitis fistula colon small intestines intestine Fistula vagina

Anal fistulas whole thickness microscopic examination the whole thickness of the intestine inflammation Non caseating

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GIT Dr. Shaf3y

clinical pictures Typical ulcerative colitis Ulcerative colitis Ulcerative colitis right iliac fossa mass small intestine Ulcerative colitis malabsorption syndrome right iliac fossa mass

appendicular mass

terminal ileum malabsorption syndrome

extra intestinal manifestations

rate of complications cancer cancer

Hemorrhage Perforation cancer risk of cancer

pseudo polyps

Investigations investigations Typical ulcerative colitis Barium Barium swallow terminal ileum terminal ileum
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Barium meal caecum

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GIT Dr. Shaf3y

String sign

post evacuation film fissures cobblestone arrangement fissures cobblestone arrangement

investigations Ulcerative colitis

ulcerative colitis

fistulas Crohns disease Crohns disease

barium fistulas fistulas ulcerative colitis

malabsoprtion

treatment Typical ulcerative colitis Typical Metrinidazole proliferation of bacteria surgical treatment failed medical treatment complications 10 routine surgery risk of cancer

risk of cancer routine surgery << surgical treatment resection anastomosis

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GIT Dr. Shaf3y

disease resection anastomosis

adhesions abdomen abdominal wall adhesion adhesions fibrosis

extensive fibrosis

resection anastomosis disease

bowel anastomosis

incision Loops of intestine Loops recurrence fistula skin skin wound wound fistula

Loops wound

wound

fistula

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GIT Dr. Shaf3y

wound fistula

appendicitis regional ileitis

adhesions

regional ileitis dysentery

as regard

Ascites
ascites

Collection of Collection of fluid in the peritoneal cavity

fluid Transudate Exudates Chylous hemorrhagic

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GIT Dr. Shaf3y

chylous ascites Obstruction of thoracic duct By Filariasis << obstruction

Lymphoma

tumor

chylous effusion milky white Rich in fat With Sudan III it becomes orange With Ether it becomes clear

Pericardial effusion chylous Hemorrhagic Hemorrhagic ascites Trauma Malignancy Bleeding tendency ( Hemorrhagic blood disease) Rupture aortic aneurysm T.B. Hemorrhagic RBCs LDH

exudates

transudate

osmotic pressure

transudates fluid transudates hydrostatic pressure

osmotic hydrostatic
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GIT Dr. Shaf3y

osmotic pressure plasma proteins Malabsorption Plasma proteins

liver cell failure

Nephrotic

malnutrition

hydrostatic pressure

hydrostatic pressure heart Right sided heart failure Tricuspid stenosis, tricuspid regurge Constrictive pericarditis Portal hypertension

ascites

Portal hypertension Hypoalbuminemia

3 gram percentage

transudate protein content of the fluid 1016 specific gravity 1000 cells International << 200 LDH

exudates Peritoneum Inflammation exudates Permeability of the blood vessels exudates Septic peritonitis T.B. peritonitis Collagen diseases Pancreatitis Spontaneous bacterial peritonitis 3 gram percentage 1,016 Protein specific gravity 200 LDH 1,000 cells

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GIT Dr. Shaf3y

ascites Symptoms ascites Abdominal distention

abdominal distention dyspnea ascites Lower limb edema dyspepsia symptoms of the cause

signs Local and general examination Local examination Inspection Abdominal distention Wide subcostal angles Divercuation of recti Shift of the umbilicus Umbilical hernia Caput medosa inspection

palpation organs by dipping masses Percussion flanks dullness shifting dullness transmitted thrill

succession splash
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auscultation vneous hum

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GIT Dr. Shaf3y

succession splash

succession splash

comatosed

comatosed comatosed

auscultation

Percussion

palpation

Anyway inspection

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GIT Dr. Shaf3y

general examination Lower limb edema Lower limb

examination

Lower limb edema Hydrocele abdominal examination Hydrocele abdominal examination

raised apex of the heart heart

apex

right sided pleural effusion diaphragm pleura Peritoneum anatomical opening right side only right side ascites right sided pleural effusion congested neck veins diaphragm ascites venous return

Intra thoracic pressure

underlying cause features Plamer erythema spider navei

Investigations ascites tapping Ultra sound treatment treatment

Liver cell failure

Underyling cause treatment of ascites

ascites

treatment of ascites treatment of the underlying cause liver cell failure treatment of ascites
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GIT Dr. Shaf3y

Liver cell failure Liver cell failure

treatment of ascites treatment of ascites Does not reduce mortality

liver cell failure

treatment of ascites does not reduce the mortality

dose not reduce mortality ascites ascites treatment

ascites

treatment dose not reduce mortality for symptomatic reasons only treatment ascites dyspnea treatment of ascites complications treatment treatment

Liver cell failure

treatment ascites treatment bed rest Load bed rest Metabolic demand

Liver Liver liver albumin

decreased metabolic demand Machinery Liver

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GIT Dr. Shaf3y

bed rest Just

fluid

fluid liter fluid diuretics

bed rest diet diet sodium sodium 80

80 Naturally Already

Which means

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GIT Dr. Shaf3y

fluid restriction Hypovolemic blood vessel fluid restriction fluids Peritoneal cavity actually Hypovolemic He is actually Hypovolemic

fluid restriction severe massive ascites fluid restriction hepatorenal syndrome Kidney fluid restriction severe cases umbilical hernia

salt restriction Proteins proteins hepatic encephalopathy hepatic encephalopathy diet

bed rest diuretics

diet

diuretics Spironolactone spironolactone

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GIT Dr. Shaf3y

potassium sparing potassium sparing Hepatic encephalopathy precipitating factors Hypokalemia spironolactone Hepatic encephalopathy spironolactone spironolactone weak diuretics Diuretics

Hypokalemia

diuresis hepato-renal gradual diuresis sudden

sudden diuresis

diuretics hypovolemia hepato-renal diuretics spironolactone potassium retaining weak diuretics

gradual

Lasilactone

spironolactone lasix << spironolactone lasix lasix lasix

hepatic encephalopathy
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lasix

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GIT Dr. Shaf3y

lasix spironolactone potassium

diuretics Albumin Human albumin plasma albumin plasma

plasma

albumin Hepatitis AIDS replacement plasma Plasma

albumin

albumin Human albumin hepatitis AIDS risk of hepatitis plasma

500

Plasma volume overload albumin albumin heart volume overload

albumin albumin Tapping para centesis severe respiratory distress Umbilical hernia about to rupture failed other measures ascetic fluid
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tapping

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GIT Dr. Shaf3y

8 hepato-renal hepatic encephalopathy gradual Para centesis

rupture

Umbilicus fluids

ascetic fluid 6- 8 gram albumin intravenous

Ascites prevent ascites blood vessel Peritoneum According to the pressure gradient ascites Pressure pressure gradient abdomen ascites abdomen pressure transudation

peritoneal sac

blood vessel

According to pressure gradient Pressure massive ascites abdomen Pressure blood vessel

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GIT Dr. Shaf3y

peritoneum Peritoneal sac blood fluid Pressure pressure

hepato-renal Hepatic encephalopathy

fluids albumin blood vessel osmotic pressure albumin blood vessels fluids retain

fluids 6 - 8 gram albumin

refractory ascites ascites not responding to medical treatment refractory ascites Not responding to medical treatment refractory ascites ascites not responding to medical treatment Spontaneous bacterial peritonitis T.B. peritonitis Malignancy Liver end stage liver disease lasix hyponateremia severe hyponateremia diuretics Urine hyponateremia glomerular filtrate
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GIT Dr. Shaf3y

Urine

hyponateremia

effective

diuresis

effective diuresis

hyponateremia mannitol Osmotic diuresis Diuretic

bleeding varices

Mannitol blood vessel Lumen blood volume varices bleeding varices This is dangerous Osmotic diuresis mannitol varices

mannitol

refractory ascites Hyponateremia varices severe hypoalbuminemia end stage liver disease

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GIT Dr. Shaf3y

spontaneous bacterial peritonitis T.B. peritonitis malignancy refractory ascites Malignancy malignancy ascetic fluid

ascites

ascites

Intra venous

ascetic fluid

fluid

intra venous hypoalbuminemia ascetic fluid

E.Coli intra venous

dirty fluid dirty ascetic fluid E.Coli septecemia

D.I.C.

ultra filtration re-infusion

vena cava

shunt Le veen Peritoneum

Shunt

One way valve << Shunt vena cava ascetic fluid D.I.C. sepsis hypervolemia addition
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GIT Dr. Shaf3y

sepsis D.I.C. hypervolemia

Liver transplant Liver transplant TIPSS Transjugular intrahepatic portosystemic stent shunting

TIPSS TIPSS TIPSS

ascites causes ascites treatment treatment ascites cause

dysentery functional gastrointestinal disorders

Functional Gastrointestinal Disorders

Functional gastrointestinal disorders functional gastrointestinal disorders organic cause disorders organic cause G.I.T. manifestations esophagus esophagus

Globus hystericus
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GIT Dr. Shaf3y

saliva repeated swallowing globus hystericus lumb Lumb clear But it does not clear

reassurance only

just reassurance chest pain of esophageal origin corkscrew esophagus Esophageal spasm angina pain pain Nitrates calcium channel blockers

regurge gastroesophageal reflux massive salivation excessive regurge gastroesphageal reflux

GERD

duodenum

stomach

gastrointestinal disorders erophagia erophagia

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GIT Dr. Shaf3y

erophagia

Non ulcerative dyspepsia peptic ulcer features features cholecystitis features Non ulcerative dyspepsia functional vomiting functional vomiting femlaes Iam talking about females females females << Females

psychogenic problem

androgen

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GIT Dr. Shaf3y

functional vomiting reassurance intestine colon Functional colonic or intestinal disorders flatulance

flatulance functional diarrhea functional diarrhea

Once

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GIT Dr. Shaf3y

No way

anxiety functional diarrhea functional diarrhea stool

functional gastrointestinal disorders irritable bowel syndrome irritable bowel syndrome

irritable bowel syndrome disease Irritable bowel syndrome disease community functional gastrointestinal disorders functional gastrointestinal disorders irritable bowel syndrome Irritable bowel syndrome irritable bowel syndrome

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GIT Dr. Shaf3y

it is a G.I.T. manifestations without an organic cause in which the patient may present by constipation or diarrhea or alternating constipation and diarrhea Associated with abdominal pain irritable bowel syndrome abdominal pain bowel habits change constipation diarrhea alternating constipation and diarrhea

etiology theories psychological is more common in type A personality << irritable bowel syndrome Irritable anxious future planners

irritable irritable bowel syndrome common

Low vegatables and fruit in the diet diet fibers irritable bowel infection has been isolated << organism allergy to certain types of food

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GIT Dr. Shaf3y

Pain Pain abdomen colics

abdomen

sigmoid spastic sigmoid

pain constipation diarrhea constipation constipation colon

stool

spastic stool

Ribbon shaped spastic colon

spasm stool stool

rabbit like stool constipation

alternating At the same time

change of bowel habits pain flatulence Excessive eructation very common

Associated type A personality Anxious, irritability bad odour of mouth ( Halitosis )

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GIT Dr. Shaf3y

dysparonia dysmenorrhea

Tension headache type A personality investigations Stool analysis colonoscopy to exclude other lesions

irritable bowel criteria criteria irritable bowel syndrome criteria abdominal pain abdominal pain defecation pain hard stool consistency change bowel frequency change irritable bowel syndrome criteria abdomen disease

soft

dysentery abdominal pain defecation pain bowel frequency change bowel consistency change dysentery criteria criteria criteria
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GIT Dr. Shaf3y

famous For nothing pioneer Just

congenital

valve lesions coronaries valve lesions

Coronaries

congenital coronaries valve lesions

valve lesions career

coronaries

research center

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GIT Dr. Shaf3y

criteria irritable bowel syndrome irritable bowel syndrome Symptomatic

abdominal colic anti spasmodic

Motility of the bowel bran bran colon spastic distention peristalsis peristalsis spastic waves

waves distention of the colon bran colon diarrhea amytriptyline laxative constipation serotonin serotonin reuptake inhibitor Serotonin reuptake inhibitor Peristalsis waves normalization constipation laxative serotonin reuptake inhibitors
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distention

Seroxat

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GIT Dr. Shaf3y

serotonin receptor agonist diarrhea anti diarrheal agent amytriptyline

as regard irritable bowel syndrome functional gastrointestinal disorders colorectal polyps MCQs << paralytic ileus intestinal obstruction Haematemesis

Haematemesis
definition of haematemesis haematemesis

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GIT Dr. Shaf3y

haematemesis haematemesis Vomiting of a blood due to a lesion proximal to the ligament of Teritz Vomiting of a blood due to a lesion proximal to the ligament of teritz

haematemesis fresh blood coffee ground

Haematemesis fresh blood Melanemesis coffee ground

haematemesis fresh blood melanemesis coffee ground rectum melena fresh blood

haematemesis esophagus Esophageal varices gastroesophageal reflux Trauma Tumors

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GIT Dr. Shaf3y

esophagus Ruptured aortic aneurysm Mallory weiss syndrome

Mallory weiss Longitudinal tear in the mucosa Longitudinal tear in the mucosa vomiting esophagus stomach stomach Peptic ulcer Fundal varices

haematemesis

stomach Angiodysplsia Carcinoma of the stomach Gastritis

stomach duodenum duodenal ulcer

duodenum

duodenal ulcer duodenum Angiodysplsia duodenum Polyposis polyps Peutz-Jaeghers Peutz-Jaeghers

Familial polyposis coli

haematemesis Haemorrhagic blood disease Purpura haemophilia Whatever

haematemesis melena melena

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GIT Dr. Shaf3y

Black tarry stool black tarry stool melena haematemesis black stool differential diagnosis Iron Charcoal Haemolytic anemia

causes of false haematemesis false haematemesis respiratory tract Upper problem bleeding nose sinusitis blood vomiting false haematemesis

haematemesis ABC airway obstruction airway ventilator wide bore cannula lab blood matching saline fresh blood Omeprazole K medical tradition vitamin K endoscopy band ligation vaso pressin vasoconstricting drugs tube Sangstaken surgical treatment peptic ulcer Omeprazole
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somatostatin

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GIT Dr. Shaf3y

ulcer adrenaline

partial resection by partial gasterectomy

approach to a patient presenting with a case of haematemesis haematemesis

G.I.T. 2013 23 31

www.facebook.com/dr.tafreegh

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