GASTRITIS - inflammation of the gastric or stomach mucosa

- affects women and men about equally

- more common in older adults

- may be acute, lasting several hours to a few days,

or chronic, resulting from repeated exposure to
irritating agents or recurring episodes of acute
gastritis

Clinical manifestations

Diagnostic and Clinical - endoscopy and histologic examination of a tissue

findings specimen obtained by biopsy

- CBC to assess for anemia as a result of

hemorrhage or pernicious anemia

Management - nasogastric (NG) intubation, antacids, histamine-2

receptor antagonists (H2 blockers) (e.g., famotidine
[Pepcid], ranitidine [Zantac]), proton pump inhibitors
(e.g., omeprazole [Prilosec], lansoprazole [Prevacid]),
and IV fluids

- Fiberoptic endoscopy may be necessary. In

extreme cases, emergency surgery may be required to
remove gangrenous or perforated tissue

- gastric resection or a gastrojejunostomy

(anastomosis of jejunum to stomach to detour around
the pylorus)
 - Chronic gastritis is managed by antacids, H2
blockers, or proton pump inhibitors

- H. pylori may be treated with selected drug

combinations which typically include a proton pump
inhibitor, antibiotics, and sometimes bismuth salts

PEPTIC ULCER - referred to as a gastric, duodenal, or esophageal

DISEASE ulcer, depending on its location

- is an excavation (hollowed-out area) that forms in

the mucosa of the stomach, in the pylorus (the
opening between the stomach and duodenum), in the
duodenum or in the esophagus)

- erosion of a circumscribed area of mucosa is the

cause.

- more likely to occur in the duodenum than in the

stomach

- Esophageal ulcers occur as a result of the

backward flow of HCl from the stomach into the
esophagus (gastroesophageal reflux disease [GERD]).

- most peptic ulcers result from infection with the

gram-negative bacteria H. pylori, which may be
acquired through ingestion of food and water

- Person-to-person transmission of the bacteria also

occurs through close contact and exposure to emesis

Risk factor - NSAIDs such as ibuprofen and aspirin is also a

major risk

- infection with H. pylori and concomitant use of

NSAIDs are synergistic risks

- smoking and alcohol consumption

- Familial tendency also may be a significant

predisposing factor
 - People with blood type O

- also associated with Zollinger–Ellison syndrome

(ZES)

Clinical manifestations - dull, gnawing pain or a burning sensation in the

midepigastrium or the back

- pyrosis vomiting

- constipation or diarrhea

- bleeding

- sour eructation (burping)

- bloating

- hematemesis (vomiting blood)

- passage of melena (black, tarry stools)

- Hypotension & tachycardia (indicating the onset

of shock)

Assessment and diagnostic - physical examination

findings
- Upper endoscopy

- serologic testing for antibodies against the H.

pylori antigen

- stool antigen test

- urea breath test

- patient who has a bleeding peptic ulcer may

require periodic CBCs

Management - peptic ulcers treated with antibiotics to eradicate

H. pylori have a lower recurrence rate than those not
treated with antibiotics
 - goals are to eradicate H. pylori as indicated and to
manage gastric acidity. Methods used include
medications, lifestyle changes, and surgical
intervention (vagotomy, gastroduodenostomy,
gastrojejunostomy)

ACHALASIA Achalasia is a rare disorder that makes it difficult for

food and liquid to pass from the swallowing tube
connecting your mouth and stomach (esophagus) into
your stomach.

Achalasia occurs when nerves in the esophagus become

damaged. As a result, the esophagus becomes
paralyzed and dilated over time and eventually loses
the ability to squeeze food down into the stomach.
Food then collects in the esophagus, sometimes
fermenting and washing back up into the mouth,
which can taste bitter. Some people mistake this for
gastroesophageal reflux disease (GERD). However,
in achalasia the food is coming from the esophagus,
whereas in GERD the material comes from the
stomach.

There's no cure for achalasia. Once the esophagus is

paralyzed, the muscle cannot work properly again.
But symptoms can usually be managed with
endoscopy, minimally invasive therapy or surgery.

Sign and Symptom Achalasia symptoms generally appear gradually and

worsen over time. Signs and symptoms may include:

· Inability to swallow (dysphagia), which may feel

like food or drink is stuck in your throat

· Regurgitating food or saliva

· Heartburn

· Belching

· Chest pain that comes and goes

· Coughing at night
 · Pneumonia (from aspiration of food into the lungs)

· Weight loss

· Vomiting

Diagnostic and Medical Achalasia can be overlooked or misdiagnosed because it

Management has symptoms similar to other digestive disorders. To
test for achalasia, your doctor is likely to recommend:

· Esophageal manometry. This test measures the

rhythmic muscle contractions in your esophagus
when you swallow, the coordination and force
exerted by the esophagus muscles, and how well your
lower esophageal sphincter relaxes or opens during a
swallow. This test is the most helpful when
determining which type of motility problem you
might have.

· X-rays of your upper digestive system

(esophagram). X-rays are taken after you drink a
chalky liquid that coats and fills the inside lining of
your digestive tract. The coating allows your doctor
to see a silhouette of your esophagus, stomach and
upper intestine. You may also be asked to swallow a
barium pill that can help to show a blockage of the
esophagus.

· Upper endoscopy. Your doctor inserts a thin,

flexible tube equipped with a light and camera
(endoscope) down your throat, to examine the inside
of your esophagus and stomach. Endoscopy can be
used to define a partial blockage of the esophagus if
your symptoms or results of a barium study indicate
that possibility. Endoscopy can also be used to collect
a sample of tissue (biopsy) to be tested for
complications of reflux such as Barrett's esophagus.

Medical Management

Achalasia treatment focuses on relaxing or stretching

open the lower esophageal sphincter so that food and
 liquid can move more easily through your digestive
tract.

Specific treatment depends on your age, health condition

and the severity of the achalasia.

Nonsurgical treatment

Nonsurgical options include:

· Pneumatic dilation. A balloon is inserted by

endoscopy into the center of the esophageal sphincter
and inflated to enlarge the opening. This outpatient
procedure may need to be repeated if the esophageal
sphincter doesn't stay open. Nearly one-third of
people treated with balloon dilation need repeat
treatment within five years. This procedure requires
sedation.

· Botox (botulinum toxin type A). This muscle

relaxant can be injected directly into the esophageal
sphincter with an endoscopic needle. The injections
may need to be repeated, and repeat injections may
make it more difficult to perform surgery later if
needed.

· Botox is generally recommended only for people

who aren't good candidates for pneumatic dilation or
surgery due to age or overall health. Botox injections
typically do not last more than six months. A strong
improvement from injection of Botox may help
confirm a diagnosis of achalasia.

· Medication. Your doctor might suggest muscle

relaxants such as nitroglycerin (Nitrostat) or
nifedipine (Procardia) before eating. These
medications have limited treatment effect and severe
side effects. Medications are generally considered
only if you're not a candidate for pneumatic dilation
or surgery, and Botox hasn't helped. This type of
therapy is rarely indicated.

Surgery

Surgical options for treating achalasia include:

 · Heller myotomy. The surgeon cuts the muscle at
the lower end of the esophageal sphincter to allow
food to pass more easily into the stomach. The
procedure can be done noninvasively (laparoscopic
Heller myotomy). Some people who have a Heller
myotomy may later develop gastroesophageal reflux
disease (GERD).

· To avoid future problems with GERD, a procedure

known as fundoplication might be performed at the
same time as a Heller myotomy. In fundoplication,
the surgeon wraps the top of your stomach around the
lower esophagus to create an anti-reflux valve,
preventing acid from coming back (GERD) into the
esophagus. Fundoplication is usually done with a
minimally invasive (laparoscopic) procedure.

· Peroral endoscopic myotomy (POEM). In the

POEM procedure, the surgeon uses an endoscope
inserted through your mouth and down your throat to
create an incision in the inside lining of your
esophagus. Then, as in a Heller myotomy, the
surgeon cuts the muscle at the lower end of the
esophageal sphincter.

POEM may also be combined with or followed by later

fundoplication to help prevent GERD. Some patients
who have a POEM and develop GERD after the
procedure are treated with daily oral medication.

CELIAC DISEASE Also known as celiac sprue or gluten enteropathy)

● is a disorder of malabsorption caused by an

autoimmune response to consumption of products
that contain the protein gluten.

Malabsorption The inability of the digestive system to

absorb one or more of the major vitamins, minerals,
and nutrients.

Gluten is most commonly found in wheat, barley, rye,

and other grains, malt, dextrin, and brewer’s yeast.

Celiac disease - prevalence of 1% in the United States.

Women are afflicted twice as often as men. - has a
 familial risk component, particularly among first-
degree relatives. - Others at heightened risk include
those with type 1 diabetes, Down syndrome, and
Turner syndrome. - may manifest at any age in a
person who is genetically predisposed.

SIGNS AND Clinical Manifestations

SYMPTOMS
More common among children than adults

• diarrhea

• steatorrhea

• abdominal pain

• abdominal distention

• flatulence (when gas builds up in the digestive system)

• weight loss.

Adults

• can present with non-GI signs and symptoms of celiac

disease, which are highly variable and can include
fatigue, general malaise, depression, hypothyroidism,
migraine headaches, osteopenia, anemia, seizures,
paresthesias in the hands and feet, and a red, shiny
tongue.

MEDICAL Assessment and Diagnostic Findings Assessment

MANAGEMENT/
DIAGNOSTIC • patient’s presenting signs and symptoms

• Family history

• Risk factor

Diagnostic

• series of serologic tests (immunoglobulin A (IgA) anti-

tissue transglutaminase (tTG))
 • Endoscopic biopsy

Evaluation of malabsorption

• Electrolytes

• ↓ Albumin

• ↓ Cholesterol

• ↓ Hemoglobin

• ↑ INR, partial thromboplastin time (PTT)

• ↓ Iron, ferritin

• ↓ Vitamin B12

• ↓ Folate

• ↑ Fecal fat

Medical Management

Celiac disease is a chronic, noncurable, lifelong disease.

There are no drugs that induce remission; the
treatment is to refrain from exposure to gluten in
foods and other products. A consult with a dietician
may be advisable.

CONSTIPATION Constipation

● Constipation is defined as fewer than three bowel

movements weekly or bowel movements that are
hard, dry, small, or difficult to pass.

At Risk

● Who recently had surgery, older adults, non-

Caucasians, and those of lower socioeconomic status.

CAUSES:

1. Medications- anticholinergic agents, antidepressants,

anticonvulsants, antispasmodics (muscle relaxants),
calcium channel antagonists, diuretic agents, opioids,
 aluminum- and calcium-based antacids, and iron
preparation

2. Other causes include weakness, immobility, debility,

fatigue, and an inability to increase intra-abdominal
pressure to facilitate the passage of stools, as may
occur in patients with emphysema or spinal cord
injury, for instance 3. Many people develop
constipation because they do not take the time to
defecate or ignore the urge to defecate

4. Constipation is also a result of dietary habits (i.e., low

consumption of fiber and inadequate fluid intake),
lack of regular exercise, and a stress-filled life

SIGNS AND Clinical manifestations of constipation include

SYMPTOMS
● Fewer than three bowel movements per week
abdominal distention

● pain and bloating

● a sensation of incomplete evacuation

● straining at stool

● and the elimination of small volume, lumpy, hard, dry

stools

MEDICAL Assessment and Diagnostic Findings

MANAGEMENT/
DIAGNOSTIC ● The diagnosis of constipation is based on the patient’s
history, physical examination, possibly the results of
a barium enema or sigmoidoscopy, and stool testing
for occult blood --These tests are used to determine
whether this symptom results from spasm or
narrowing of the bowel

● Anorectal manometry (i.e., pressure studies such as a

balloon expulsion test) may be performed to assess
malfunction of the sphincter.
 ● Defecography and colonic transit studies can also assist
in the diagnosis because they permit assessment of
active anorectal function.

● Tests such as pelvic floor magnetic resonance imaging

(MRI) may identify occult pelvic floor defects.

Medical Management

● Education, exercise, bowel habit training, increased

fiber and fluid intake, and judicious use of laxatives

○ EDUCATION- sit on the toilet with legs supported

and to utilize the gastrocolic reflex (peristaltic
movement

○ Routine exercise to strengthen abdominal muscles is

encouraged

○ Daily dietary intake of 25 to 30 g/day of fiber (soluble

and bulk forming) is recommended, especially for the
treatment of constipation in the older adult.

○ If laxative use is necessary, one of the following may

be prescribed: bulk-forming agents (fiber laxatives),
saline and osmotic agents, lubricants, stimulants, or
fecal softener

DIARRHEA Diarrhea

● Diarrhea is an increased frequency of bowel

movements (more than 3 per day) with altered
consistency (i.e., increased liquidity) of stool

● Any condition that causes increased intestinal

secretions, decreased mucosal absorption, or altered
motility can produce diarrhea.

FACTORS OF DIARRHEA

● perianal discomfort,

● incontinence,

● nausea, or a combination of these factors

 3 CLASSIFICATIONS

1. Acute diarrhea is self-limiting, lasting 1 or 2 days

2. Persistent diarrhea typically lasts between 2 and 4

weeks

3. Chronic diarrhea persists for more than 4 weeks and

may return sporadically

SIGNS AND Clinical Manifestations

SYMPTOMS
● increased frequency and fluid content of stools

● abdominal cramps

● distention

● borborygmus (i.e., a rumbling noise caused by the

movement of gas through the intestines)

● anorexia, and thirst.

● Painful spasmodic contractions of the anus and

tenesmus (i.e., ineffective, sometimes painful
straining with a strong urge) may occur with
defecation.

● Other symptoms depend on the cause and severity of

the diarrhea but are related to dehydration and to fluid
and electrolyte imbalances.

● Voluminous, greasy stools- suggest intestinal

malabsorption

● Presence of blood, mucus, and pus- Suggest

inflammatory enteritis or colitis

● Oil droplets on the toilet water may be suggestive of

pancreatic insufficiency

● Nocturnal diarrhea may be a manifestation of diabetic

neuropathy
MEDICAL GOAL : Control symptoms, preventing complications,
MANAGEMENT/ and eliminating or treating the underlying disease
DIAGNOSTIC

1. INFECTION Control measure until di madetermine

yung cause ng diarrhea

2. Reduce the severity of the diarrhea and treat the

underlying disease- antibiotics, anti-inflammatory
agents) and antidiarrheal agents (e.g., loperamide
[Imodium], diphenoxylate with atropine [Lomotil])

Assessment and Diagnostic Findings

● complete blood cell count (CBC)

● serum chemistries

● urinalysis

● routine stool examination and stool examinations for

infectious or parasitic organisms

● bacterial toxins

● blood, fat

● electrolytes,

● white blood cells

● Endoscopy or barium enema may assist in identifying

the cause

FECAL FECAL INCONTINENCE

INCONTINENCE
● Fecal incontinence describes the recurrent involuntary
passage of stool from the rectum for at least 3 months
 ● Factors: Factors that influence this disorder include the
ability of the rectum to sense and accommodate stool,
the amount and consistency of stool, the integrity of
the anal sphincters and musculature, and rectal
motility

SIGNS AND Clinical Manifestations

SYMPTOMS
● Patients may have minor soiling, occasional urgency
and loss of control, or complete incontinence.

● Patients may also experience poor control of flatus,

diarrhea, or constipation. Passive incontinence occurs
without warning; whereas, patients with urge
incontinence have the sensation of the urge to
defecate but cannot reach the toilet in time

MEDICAL DIAGNOSTIC EXAMS

MANAGEMENT/
DIAGNOSTIC ● Assessing the patient’s medical history is helpful in
identifying the most likely etiology

. ● Diagnostic studies are necessary because the

treatment of fecal incontinence depends on the cause.

● A rectal examination and an endoscopic examination

such as a flexible sigmoidoscopy are performed to
rule out tumors, inflammation, fissures, or impaction.

● Anorectal manometry, anal endosonography, pelvic

MRI scan, and transit studies may be helpful in
identifying alterations in intestinal mucosa and
muscle tone or in detecting other structural or
functional problems

MANAGEMENT

Medical Management Main Goal: correcting the

underlying cause

1. Diarrhea-the incontinence may disappear when

diarrhea is successfully treated. Some patients benefit
 from the addition of psyllium (Metamucil) as a fiber
supplement. In addition, administering loperamide 30
minutes prior to meals can be an effective
intervention in some patient

2. Fecal impaction may cease after the impaction is

removed and the rectum is cleansed

3. If the fecal incontinence is related to the use of

contributory drugs (e.g., laxatives, antacids
containing magnesium), the incontinence may
improve or cease when the drug regimen is altered

4. Biofeedback therapy with pelvic floor muscle training

IF ANG PROB IS decreased sensory awareness or
sphincter control

5. Bowel training programs can also be effective.

6. Surgical procedures include surgical reconstruction or

repair of anal sphincter, artificial sphincter
implantation, anal sphincter bulking by injection of
synthetic agents, sacral nerve stimulation, or fecal
diversion

HIATAL HERNIA A hiatal hernia occurs when a portion of the stomach

prolapses through the diaphragmatic esophageal
hiatus. Most hiatal hernias are asymptomatic and are
discovered incidentally, but rarely, a life-threatening
complication may present acutely.

Hiatal hernia include:

A. Sliding esophageal hernia.

The upper stomach and gastroesophageal

junction have moved upward and slide in and

out of the thorax.

B. Paraesophageal hernia.
 All or part of the stomach pushes through the

diaphragm next to the gastroesophageal

junction

NOTE: There is also an association between obesity and

the presence of hiatal hernia. By far, most hiatal
hernias are asymptomatic and are discovered
incidentally. On rare occasion, a life-threatening
complication, such as gastric volvulus or
strangulation, may present acutely.

SIGNS AND SYMPTOMS Complications of hiatal hernia may include the following:

ü Intermittent bleeding from associated esophagitis,

erosions (Cameron ulcers), or a discrete esophageal
ulcer, leading to iron-deficiency anemia

ü Incarcerated hiatal hernia (rare; observed only with

paraesophageal hernia)

The physical examination usually is unhelpful. Certain

conditions may predispose to the development of
hiatal hernia, including the following:

ü Muscle weakening and loss of elasticity with age

ü Pregnancy

ü Obesity

ü Abdominal ascites

MEDICAL The doctor may do tests including:

MANAGEMENT/
DIAGNOSTIC · Barium swallow

· Endoscopy

· Esophageal manometry
 MEDICAL MANAGEMENT:

· Antacids that neutralize stomach acid. Antacids, such as

Mylanta, Rolaids and Tums, may provide quick
relief. Overuse of some antacids can cause side
effects, such as diarrhea or sometimes kidney
problems.

· Medications to reduce acid production. These

medications — known as H-2-receptor blockers —
include cimetidine (Tagamet HB), famotidine (Pepcid
AC) and nizatidine (Axid AR). Stronger versions are
available by prescription.

· Medications that block acid production and heal the

esophagus. These medications — known as proton
pump inhibitors — are stronger acid blockers than H-
2-receptor blockers and allow time for damaged
esophageal tissue to heal. Over-the-counter proton
pump inhibitors include lansoprazole (Prevacid
24HR) and omeprazole (Prilosec, Zegerid). Stronger
versions are available in prescription form.

SURGERY:

Gastrectomy

Laparoscopy

NOTE: Surgery is generally used for people who aren't

helped by medications to relieve heartburn and acid
reflux, or have complications such as severe
inflammation or narrowing of the esophagus.

• Intestinal obstruction is a blockage that keeps food or

INTESTINAL liquid from passing through your small intestine or large
OBSTRUCTION intestine (colon).
• Causes of intestinal obstruction may include fibrous
bands of tissue (adhesions) in the abdomen that form
after surgery; hernias; colon cancer; certain medications;
or strictures from an inflamed intestine caused by certain
conditions, such as Crohn's disease or diverticulitis.
Signs and Symptoms · Crampy abdominal pain that comes and goes

· Loss of appetite

· Constipation, Diarrhea

· Vomiting, Nausea

· Inability to have a bowel movement or pass gas

· Swelling of the abdomen

Causes The most common causes of intestinal obstruction in

adults are:

· Intestinal adhesions — bands of fibrous tissue in

the abdominal cavity that can form after abdominal or
pelvic surgery

· Hernias — portions of intestine that protrude into

another part of your body

· Colon cancer

In children, the most common cause of intestinal

obstruction is telescoping of the intestine
(intussusception).

Other possible causes of intestinal obstruction include:

· Inflammatory bowel diseases, such as Crohn's

disease

· Diverticulitis — a condition in which small,

bulging pouches (diverticula) in the digestive tract
become inflamed or infected

· Twisting of the colon (volvulus)

· Impacted feces
Risk factors · Abdominal or pelvic surgery, which often causes
adhesions — a common intestinal obstruction

· Crohn’s disease, which can cause the intestine’s

walls to thicken, narrowing the passageway

· Cancer in your abdomen

• Tissue death
Complications • infection

• Physical exam
Diagnosis • X-ray
• Ct scan
• Ultrasound
• Air or barioum enema

• Hospitalization for stabilizing the condition

Treatment • Treating intussusception
• Treating partial obstruction
• Treating complete obstruction
• Treating pseudo-obstruction