Bộ máy Tiêu Hóa (Digestive System)

(tham khảo trong chapter 4 sách Clinical Pathophysiology của Aaron Berkowitz)

B- Diseases of the Stomach

Dạ dầy nghiền nát đồ ăn, tiết ra acid để thủy phân (acid hydrolysis bẻ nhỏ các phân tử đồ
ăn), đẩy xuống duodenum qua pyloric sphincter (để tiếp tục tiêu hóa bằng dịch tụy và bilirubin từ
gan) và tiết ra intrinsic factor (giúp cho sự hấp thụ B12 qua màng ruột). Vì dạ dầy tiết ra acid nên
phải có gastric mucosal lining để protection.
Peptic Ulcer Diseases PUD (gồm gastric ulcer & duodenal ulcer)
Etiology: Peptic Ulcer do lượng acid tiết ra nhiều quá hay màng bảo vệ mucosal protection/mucus
secretion giảm kém (coi fig.4-3):
- Gastrin là một hormone tiết ra bởi G-cells trong dạ dầy kích thích acid secretion. Zollinger-
Ellison syndrome do pancreatic tumor tên là gastrinoma tiết ra gastrin acid multiple ulcers at
different sites. In the body of the stomach, the vagal postganglionic muscarinic nerves
release acetylcholine(ACh) which stimulates parietal cell H+ secretion.
Đặc biệt trong Zollinger-Ellison syndrome secretin stimulate pancreatic gastrinoma tiết ra gastrin
mà bình thường secretin cùng với somastatin, prostaglandins, VIP làm giảm acid secretion và
không stimulate normal pancreas tiết ra gastrin được (coi fig.4-4 và 4-2)
Secretin do small intestine tiết ra khi đồ ăn xuống, stimulate pancreas tiết ra bicarbonate để
neutralize acid trong duodenum.
 Specifically, somatostatin affects the pituitary gland in that it causes inhibition of
secretion of growth hormone which is vital to cells in growth and metabolism. In the
pancreas, somatostatin inhibits the secretion of insulin and glucagon which play an
important role in glucose regulation in the body.
Alpha cells (A cells) secrete the hormone glucagon. Beta cells (B cells) produce
insulin and are the most abundant of the islet cells. Delta cells (D cells) secrete the
hormone somatostatin, which is also produced by a number of other endocrine cells in
the body.
 Helicobacter Pylori H.Pylori làm tăng acid secretion và làm giảm mucosal
protection gây ulcer và lâu ngày gây cancer:

●Ulcers may cause no symptoms, or may cause pain or discomfort.

●H. pylori can be diagnosed with a test of the blood, urea breath test, stool,
endoscopy with biopsy
●H. pylori treatment usually includes several medicines. At least two of the
medicines are antibiotics that help to kill the bacteria. The other medication causes
the stomach to make less acid; lower acid levels help the ulcer to heal.
 ●Most people are cured after finishing two weeks of medicine. Some people need to
take another two weeks of medicine.
●Guidelines recommend that all patients treated for H. pylori undergo a breath or
stool test two weeks after finishing the medication.This is done to be sure that the
bacteria were killed.

NSAIDS làm giảm đau và giảm inflammation nhưng đồng thời làm giảm mucus secretion
nên gây ulcers.
Stress làm giảm mucus secretion e.g. trong shock (sepsis, burn, hemorrhage, lo buồn) nên
các bệnh nhân thường được uống thuốc anti-ulcer để phòng ngừa khi nhập viện.
Thuốc lá, Rượu, Radiation cũng làm giảm mucus secretion gây ulcer.
Symptome & Signs of PUD: pain, nausea, vomiting with red blood or digested blood (coffee
ground bã cà phê), melena (tarry stool phân đen như hắc in trải đường), lâu ngày gây gastric or
duodenal perforation peritonitis (đau cứng bụng, air under diaphragm on upright CXR).
Time of ulcer symptoms: Thường ăn xong đau ngay là gastric ulcer, ăn xong vài giờ sau mới đau
là duodenal ulcer (coi fig.4-5). Tuy nhiên có nhiều kiểu đau tùy theo người bệnh, phải làm
endoscopy và trong trường hợp gastric ulcer luôn luôn phải làm biopsy để rule out cancer.
 Ulcer Treatment: PUD do increased acid secretion, decreased mucosal protection và H.Pylori.
Vậy treatment gồm neutralize bớt acid, ngăn ngừa acid secretion, tăng mucosal protection và
triệt tiêu H.Pylori.
* Neutralize acid bằng base (e.g. antacid như milk of magnesium, Tums tablets).
* Triệt tiêu H.pylori bằng antibiotics như trên đã nói.
* Giảm acid secretion & tăng mucosal protection (coi fig.4-6):

Histamine bám vào H2 receptors trên gastric parietal cells để stimulate acid secretion.

H2 blockers (e.g. ranitidine) block H2 receptors như vậy histamine không bám vào được để
stimulate acid secretion.

Vagotomy tỉa bớt vagus nerve (CN X) vì vagus nerve là parasympathetic gây acid secretion. CN X chạy
từ brain stem qua cổ, dọc theo esophagus, stomach tới intestines. Bây giờ có nhiều thuốc hay nên ít khi
phải làm vagotomy (trừ khi medications không kết quả). Vagotomy có nhiều nấc: truncal vagotomy (tỉa
cắt CN X ngay từ chỗ mới chạy vào esophagus), selective vagotomy (cắt tỉa CN X gần với stomach), highly
selective vagotomy (cắt sát CN X trong stomach để tránh ảnh hưởng tới các viscera khác), thường hay làm
với pyroloplasty (mở rộng pylorus để partially digested foods và dịch tiêu hóa xuống duodenum).
Sucralfate là một lớp viscous gel phủ lên mặt dạ dầy để bảo vệ. Misoprostol (a synthetic prostaglandin)
làm tăng mucosal protection.
Sau cùng other causes of Gastritis là other infections, reflux of bile and/or pancreatic secretions and
Crohn’s disease (chronic inflammatory bowel disease that affects the lining of the digestive tract--> pain,
diarrhea, weight loss, fatigue).
Loss of Intrinsic Factor
Parietal cells of the stomach produce intrinsic factor which binds B12, facilitating its intestinal
absorption. Autoimmune gastritis (antibodies phá parietal cells không produce được intrinsic
factor) B12 không absorbed được sinh ra pernicious anemia.
Obstruction
Etiology:Thường đồ ăn từ stomach xuống duodenum phải qua pyloric sphincter. Đó là chỗ gây trở
ngại Obstruction từ trong (foreign body, gastric polyp or gastric cancer), từ ngoài đè vào (pancreatic
tumor). Ngoài ra pylorus có thể bị sẹo scarred do PUD hay caustic ingestion và congenital pyloric
stenosis ở em bé mới sinh (cần surgical opening of the sphincter ngay).
Symptoms & signs: vomiting, early satiety (ăn chóng no), abdominal distention, visible waves of
peristalsis (dạ dầy cố bóp chống với obstruction nhu động nổi cuồn cuộn trên bụng), palpable olive-
like mass to palpation trong congenital pyloric stenosis.
Gastroparesis
Gastroparesis là paralysis of the stomach do tổn thương vagus nerve (CN X) vì diabetic neuropathy
or other neurological diseases, các thuốc block acetylcholine (parasympathetic nerve release
acetylcholine at their synapses) hay gastric motility như narcotic analgesics.
Gastric Cancer
Người Á Châu, người có tiền sử gastritis, ulcer, H.Pylori, pernicious anemia hay bị ung thư dạ dầy
thường là adenocarcinoma. Triệu chứng rất ít (ói mửa, chóng no, GI bleeding). Khi biết thường đã trễ
khó cứu (treatment bằng surgery, chemotherapy, radiation).

C- Diseases of the Small Intestine

Khúc nào trong ống tiêu hóa cũng có thể xảy ra: inflammation (e.g. Crohn’s disease), obstruction, tumors,
bleeding kể cả small intestine nhưng chức vụ chính của small intestine là Absorption nên bệnh lý chính
của small intestine là Malabsorption khó hấp thụ (fig.4-7).
Chú thích: đồ ăn bị dạ dầy nghiền nát và phá vỡ, xuống duodenum, kích thích duodenum tiết ra
cholecystokinin (CCK) và secretin which stimulate the gallbladder bile and the pancreas
bicarbonate + digestive enzymes (coi các sơ đồ dưới đây) rồi sẽ được hấp thụ qua màng ruột (ở
đây lại bị metabolized by cells of the gut wall) để vào blood stream hay vào lymphatic circulation.
Problems with Digestion: failure of stomach acid secretion or churning, failure of enzyme
secretion into the gut lumen (pancreatic insufficiency decreased digestive enzyme secretion,
liver disease or gall bladder obstruction decreased bile acids, duodenal resection loss of
CCK+secretin decreased pancreatic & gallbladder secretion), failure or decrease of an enzyme
(lactase deficiency lactose intolerance).
Problem with Absorption: reduced surface area (resection of bowel, damage of absorbing area do Crohn’s
disease, parasite infection, drugs, radiation, sprue: gluten sensitive enteropathies), intracellular metabolic
aberrations in transport (e.g. Abetalipoproteinemia, an inherited disorder that impairs the normal absorption of fats and
certain vitamins from the diet. Many of the signs and symptoms of abetalipoproteinemia result from a severe shortage (deficiency)
of fat-soluble vitamins (vitamins A, E, and K), obstruction of the lymphatics/lacteals (e.g.by tumor) .
A lacteal is a lymphatic capillary that absorbs dietary fats in the villi of the small intestine. Triglycerides are
emulsified by bile and hydrolyzed by the enzyme lipase, resulting in a mixture of fatty acids, di- and monoglycerides.
... At this point, the fats are in the bloodstream in the form of chylomicrons.

Obstruction: post-surgical adhesions, tumors rất hiếm, nearby tumors in other organs (pancreas),
gallstones, hernia, Crohn’s disease. Nếu complete small intestine obstruction phải mổ ngay còn
các functional partial obstruction thì nhịn ăn, IV fluid, đặt ống nasogastric tube decompression
cho hơi thoát ra.

Small Bowel Tumors: rất hiếm (bướu lành như adenoma, lipoma: bướu ác như adenocarcinoma,
lymphoma, carcinoids).

Symptoms of Crohn’s disease include abdominal pain, cramping, blood in the stool,
diarrhea, nausea, vomiting, urgent need to go to the bathroom, loss of appetite, weight loss and
lack of energy. Crohn’s disease is painful and often debilitating and can sometimes lead to life-
threatening complications. Crohn’s disease has a profound effect on quality of life and has a
shortening of life expectancy of about three years. Crohn’s disease can also leads to elevated
rates of colorectal cancer.
 D- Diseases of the Large Intestine
Các vấn đề thường xảy ra trong ống tiêu hóa GI tract là: tumors (colon cancer), inflammation
(ulceratice colitis, Crohn’s disease), obstruction (mostly due to colon cancer) và bleeding cũng
xảy ra cho large intestine. Ngoài ra đặc biệt là đại trường có 2 nhiệm vụ chính là hấp thụ nước &
sodium và bài tiết phân ra ngoài cho nên 2 bệnh chính của colon là

Constipation (táo bón) & Diarrhea (tiêu chảy)

Hirschprung’s disease (constipation in children) do 1 khúc ruột già không có parasympathetic

nerve (bệnh bẩm sinh congenital) nên không co bóp sinh táo bón, phía trên proximal dãn to ra
megacolon. Phải giải phẫu cắt bỏ khúc đó đi và nối 2 đầu ruột bình thường.
Diverticulosis do ăn ít rau cỏ táo bón đi cầu BM phải rặn lâu ngàylàm yếu thành
ruộtdiverticula (thường ở descending colon bên hông trái LLQ) gọi là bệnh diverticulosis sinh
biến chứng: inflammed diverticula or diverticulitis (đau sốt nóng như appendicitis nhưng ở bên
hố chậu trái), ruptured diverticula dính thông với urine bladder hơi ruột vào urine
(pneumaturia) hay phân ruột vào urine (fecaluria)
Diarrhea do excessive secretion, decreased absorption và presence of some substances that
increase osmolarity of the colonic contents:
*Điển hình nhất là Dịch Tả (cholera) do vi khuẩn Vibrio Cholera tiết ra một toxinincrease
chloride Cl & potassium K secretion từ tế bào thành ruột vào ống ruột lumen, lại không cho
sodium Na được hấp thụ Na absorption (from the lumen into the cells) nên nước không theo Na
hấp thụ vào máu được decreased water absorption và Cl, K, Na increase luminal osmolarity
hút nước ra ruột diarrhea (té re tè chảy, hết nước là chết nếu không truyền dịch kịp). Các vi
khuẩn khác (E.Coli, Shigella, Salmonella, Campilobacter,..) gây diarrhea cũng theo cùng một cơ
chế đó.
* VIPoma là một bướu trong pancreas tiết ra nhiều VIP quá pancreatic chlolera. Bình thường
pancreas tiết ra VIP có tác dụng giảm gastric secretion, relaxe gut musculature và tăng pancreatic
bicarbonate secretion. Nếu nhiều quá, VIP sẽ làm tăng secretion và giảm absorption diarrhea

Colon Cancer (adenocarcinoma) là một trong số the most common cancers cho nên phải
screening bằng colonoscopy (soi ruột định kỳ) sau 50 tuổi. Ai có người trong gia đình bị colon
cancer thì phải làm colonoscopy 10 năm trước năm tuổi của người trong gia đình bị colon cancer.
Triệu chứng mới đầu rất ít, chỉ chảy máu rất ít often occult bleeding phát hiện bằng fecal occult
blood test FOBT hay Guaic test. Khi có triệu chứng abdominal pain, changes in bowel habits, lower
bleeding (máu đỏ hơn và nhiều hơn), obstruction thì đã nặng quá rồi. Chữa trị bằng surgery,
chemotherapy hay radiation. Nếu thấy polyps nhất là sessile polyps khi làm colonoscopy thì phải
coi chừng sẽ trở thành cancer. CT Colonography là một Virtual Colonoscopy (less aggressive, phát
hiện được những polyps nhỏ nhưng không cắt bỏ được và không làm biopsy được nên sau đó
phải làm colonoscopy).
Fecal occult blood tests FOBT

Currently, there are 2 types of FOBTs:

 Guaiac-based FOBT. During the test, you place a stool sample on a test card coated
with a plant-based substance called guaiac. The card changes color if blood is in the stool.
Some guaiac-based FOBTs use flushable pads instead of a card. They are available without
a prescription at many drugstores. Results are available to the user right away.
  Immunochemical FOBT. This test uses a specialized protein called an antibody. This
specific protein attaches to hemoglobin, the oxygen-carrying part of red blood cells.
Preparation for a FOBT depends on the type of test you take

Guaiac test: diet several days before the test: Increase fiber intake, Avoid specific foods (red meat
and certain vegetables), Avoid certain vitamin supplements (vitamin C and iron)
Immunochemical test. No dietary changes for this test. But need to avoid certain medicines
(Aspirin or other over-the-counter pain medications and blood-thinning medications may change
the test results of both types of FOBTs). The test should not be taken if you have bleeding
hemorrhoids, peptic ulcers, or gastritis. And women who are near the time of menstruation
should not take the test.
Using cards. You will need to collect 3 stool samples in a row for this test. These are stored in a
supplied container or placed on a test card with an applicator.
Using flushable pads. You will drop the pad into the toilet bowl after a bowel movement. You
will then repeat this procedure for the next 2 bowel movements. The pads change color when
blood is present in the toilet bowl.

Inflammatory Bowel Disease IBD (Crohn’s Disease & Ulcerative Colitis)

Diagnosis
Blood tests
 Tests for anemia or infection (CBC) to check for anemia or to check for signs of infection
from bacteria or viruses.
 Fecal occult blood test.

Endoscopic procedures

 Colonoscopy. This exam allows your doctor to view your entire colon using a thin, flexible,
lighted tube with an attached camera. During the procedure, your doctor can also take
small samples of tissue (biopsy) for laboratory analysis. Sometimes a tissue sample can help
confirm a diagnosis.
  Flexible sigmoidoscopy. Your doctor uses a slender, flexible, lighted tube to examine the
rectum and sigmoid, the last portion of your colon. If your colon is severely inflamed, your
doctor may perform this test instead of a full colonoscopy.
 Upper endoscopy. In this procedure, your doctor uses a slender, flexible, lighted tube to
examine the esophagus, stomach and first part of the small intestine (duodenum). While it
is rare for these areas to be involved with Crohn's disease, this test may be recommended
if you are having nausea and vomiting, difficulty eating or upper abdominal pain.
 Capsule endoscopy. This test is sometimes used to help diagnose Crohn's disease
involving your small intestine. You swallow a capsule that has a camera in it. The images are
transmitted to a recorder you wear on your belt, after which the capsule exits your body
painlessly in your stool. You may still need an endoscopy with a biopsy to confirm a
diagnosis of Crohn's disease.
 Balloon-assisted enteroscopy. For this test, a scope is used in conjunction with a device
called an overtube. This enables the doctor to look further into the small bowel where
standard endoscopes don't reach. This technique is useful when a capsule endoscopy shows
abnormalities, but the diagnosis is still in question.
Imaging procedures
 X-ray. If you have severe symptoms, your doctor may use a standard X-ray of your
abdominal area to rule out serious complications, such as a perforated colon.
 Computerized tomography (CT) scan. You may have a CT scan — a special X-ray
technique that provides more detail than a standard X-ray does. This test looks at the entire
bowel as well as at tissues outside the bowel. CT enterography is a special CT scan that
provides better images of the small bowel. This test has replaced barium X-rays in many
medical centers.
 Magnetic resonance imaging (MRI). An MRI scanner uses a magnetic field and radio
waves to create detailed images of organs and tissues. An MRI is particularly useful for
evaluating a fistula around the anal area (pelvic MRI) or the small intestine (MR
enterography). Unlike a CT, there is no radiation exposure with an MRI.
Treatment
The goal of inflammatory bowel disease treatment is to reduce the inflammation that triggers
your signs and symptoms. In the best cases, this may lead not only to symptom relief but also to
long-term remission and reduced risks of complications. IBD treatment usually involves either
drug therapy or surgery.

Anti-inflammatory drugs
Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease.
Anti-inflammatories include corticosteroids (prednisone) and aminosalicylates, such as
mesalamine (Asacol HD, Delzicol, others), balsalazide (Colazal) and olsalazine (Dipentum). Which
medication you take depends on the area of your colon that's affected.

Immune system suppressors

These drugs work in a variety of ways to suppress the immune response that releases
inflammation-inducing chemicals in the intestinal lining. For some people, a combination of these
drugs works better than one drug alone.
Some examples of immunosuppressant drugs include azathioprine (Azasan, Imuran),
mercaptopurine (Purinethol, Purixan), cyclosporine (Gengraf, Neoral, Sandimmune) and
methotrexate (Trexall).
One class of drugs called tumor necrosis factor (TNF)-alpha inhibitors, or biologics, works by
neutralizing a protein produced by your immune system. Examples include infliximab (Remicade),
adalimumab (Humira) and golimumab (Simponi). Other biologic therapies that may be used are
natalizumab (Tysabri), vedolizumab (Entyvio) and ustekinumab (Stelara).

Antibiotics
Antibiotics may be used in addition to other medications or when infection is a concern — in
cases of perianal Crohn's disease, for example. Frequently prescribed antibiotics include
ciprofloxacin (Cipro) and metronidazole (Flagyl).

Other medications and supplements

In addition to controlling inflammation, some medications may help relieve your signs and
symptoms:

 Anti-diarrheal medications. A fiber supplement — such as psyllium powder (Metamucil)

or methylcellulose (Citrucel) — can help relieve mild to moderate diarrhea by adding bulk
to your stool. For more severe diarrhea, loperamide (Imodium A-D) may be effective.

 Pain relievers. For mild pain, your doctor may recommend acetaminophen (Tylenol,
others). However, ibuprofen (Advil, Motrin), naproxen sodium (Aleve) and diclofenac
 sodium (Voltaren) likely will make your symptoms worse and can make your disease worse
as well.

Iron supplements. If you have chronic intestinal bleeding, you may develop iron
deficiency anemia and need to take iron supplements.

 Calcium and vitamin D supplements. Crohn's disease and steroids used to treat it can
increase your risk of osteoporosis, so you may need to take a calcium supplement with
added vitamin D.

Nutritional support

Your doctor may recommend a special diet given via a feeding tube (enteral nutrition) or
nutrients injected into a vein (parenteral nutrition) to treat your IBD. This can improve your
overall nutrition and allow the bowel to rest. Bowel rest can reduce inflammation in the short
term.
If you have a stenosis or stricture in the bowel, your doctor may recommend a low-residue diet.
This will help to minimize the chance that undigested food will get stuck in the narrowed part of
the bowel and lead to a blockage.

Surgery
If diet and lifestyle changes, drug therapy, or other treatments don't relieve your IBD signs and
symptoms, your doctor may recommend surgery.

 Surgery for ulcerative colitis. Surgery can often eliminate ulcerative colitis. But that
usually means removing your entire colon and rectum (proctocolectomy).
In most cases, this involves a procedure called an ileal pouch anal anastomosis. This
procedure eliminates the need to wear a bag to collect stool. Your surgeon constructs a
pouch from the end of your small intestine. The pouch is then attached directly to your
anus, allowing you to expel waste relatively normally.
In some cases a pouch is not possible. Instead, surgeons create a permanent opening in
your abdomen (ileal stoma) through which stool is passed for collection in an attached bag.

 Surgery for Crohn's disease. Up to one-half of people with Crohn's disease will require at
least one surgery. However, surgery does not cure Crohn's disease.
During surgery, your surgeon removes a damaged portion of your digestive tract and then
reconnects the healthy sections. Surgery may also be used to close fistulas and drain
abscesses.
The benefits of surgery for Crohn's disease are usually temporary. The disease often recurs,
frequently near the reconnected tissue. The best approach is to follow surgery with
medication to minimize the risk of recurrence
IBD (Inflammatory Bowel Disease) IBS (Irritable Bowel Syndrome)

Classified as a disease
Can cause destructive inflammation and permanent
harm to the intestines (Crohn’s Disease, Ulcerative
Colitis)
The disease can be seen during diagnostic imaging
Increased risk for colon cancer
Classified as a syndrome, defined as a
group of symptoms
Does not cause inflammation; rarely
requires hospitalization or surgery
There is no sign of disease or
abnormality during an exam of the
colon
No increased risk for colon cancer or
IBD

Symptoms of IBS (considered as functional enteropathy)

IBS symptoms and their intensity can vary from person to person. Symptoms often occur after
eating a large meal or when you are under stress, and they are often temporarily relieved by
having a bowel movement.
 Chronic and persistent abdominal pain
 Constipation alternating with diarrhea
 Mucus in the stool
 Gassiness
 Abdominal bloating, or the sensation of feeling full
 Abdominal distention, or swelling
 The urge to move your bowels without being able to have a bowel movement
 Nausea
Anemia, bleeding, weight loss, and fever are symptoms of IBD, not IBS

Diagnosing IBS
IBS is diagnosed based on your symptoms and elimination of other causes. Your doctor will take
a detailed medical history and perform a thorough physical exam. Unlike IBD, IBS cannot be
confirmed by visual examination or with diagnostic tools and procedures, though your doctor
may use blood and stool tests, x-ray, endoscopy, and psychological tests to rule out other
diseases.
Other criteria for diagnosing IBS includes having abdominal discomfort or pain for at least 12
weeks, even if non-consecutive, over the past 12 months, accompanied by at least two of the
following symptoms:
 relief upon defecation
 onset associated with a change in your stool frequency
 onset associated with a change in the form of your stool
Causes of IBS
Like with Crohn’s disease and ulcerative colitis, the cause of IBS is not fully understood. Stress
can aggravate IBS, the syndrome is caused by a disturbance between the brain and the gut.

IBS Treatment
Available treatments target the symptoms to provide relief. This is often the first line of
treatment. In mild cases, IBS symptoms can be managed with dietary changes and stress
reduction techniques. No one medication that works for all IBS patients.

Psychological Therapy
Some IBS patients benefit from seeing a therapist for cognitive behavioral therapy, stress
management, or relaxation training.

Localizing GI Bleeding (fig.4-9)

Thường upper GI bleeding gần mồm (esophageal varices) hay lower GI bleeding gần hậu môn (hemorrhoid) máu
bright red, xa 2 đầu (stomach) thì như bã cà phê (coffee ground) hay nhựa đường black/tarry (melena). Đặc biệt
trong massive gastric bleeding tuy xa 2 đầu nhưng máu chưa kịp digested nên vẫn bright red hay ngược lại nếu
slow colonic bleeding máu chậm ra nên trở thành black tarry (melena).