Scientific Team

wateen
  Endoscopy is a nonsurgical procedure used to examine a person from inside. Using an
endoscope, a flexible tube with a light and camera attached to it, your doctor can view
pictures of your digestive tract on a color TV monitor.

git‫ للمريض بحيث بتم عرض ما هو داخل ال‬git ‫ عبارة عن أنبوب مع ضوء وكاميرا ممكن ندخل داخل ال‬endoscopy ‫ال‬

 This procedure can be diagnostic or/and therapeutic

‫هاد االجراء ممكن يكون لتشخيص المرض او لعالجه‬

 There are many types of endoscopy, and here are some of them:

 Upper endoscopy

‫هاد النوع يتم من خالله ادخال االنبوب من الفم ليصل الى المريء ووممكن يوصل للمعدة‬
dudenum‫وال‬

 Sigmoidoscopy

sigmoid clon‫ حتى نصل لل‬rectum ‫ يتم إدخاله من ال‬rigid ‫أنبوب بكون‬

 Colonoscopy

‫عشان يدخل داخل انثناءات القولون ممكن يوصل‬flexible ‫نفس االجراء بس بكون االنبوب‬
terminal illum‫لل‬

 ERCP (Endoscopic retrograde cholangiopancreatography)

Mouth---esophagus---stomach---dudenum—ampulla of vater

‫وممكن‬pancreatic duct and billary tree ‫(عشان نكشف اذا فيه انسداد في‬contrast media) ‫بعدين يتم حقن مادة‬
‫تستخدم ايضا للعالج‬
 Laparoscopy

Surgical procedure----at which the tube will be inserted in the abdomen

 Bronchoscopy

Nose---nasal cavity---nasopharynx---larynx---trachea-----to expose vocal cords and folds

 Arthroscopy

To expose the joint----usually knee joint

 Cystoscopy

To expose the urinary bladder

 During an upper endoscopy( also called esophagogaastroduodenoscopy), an endoscope is

easily passed through the mouth and throat and into the esophagus, allowing the doctor to
view the esophagus, stomach, and upper part of the small intestine.

‫نفس التعريف الي فوق بس االختالف اسمه االخر‬

esophagogaastroduodenoscopy
 ‫بالصورة األولى‪----‬الي معلم باالسود‪-----‬ال‪gastro esophageal junction‬‬

‫بالصورة الثانية‪----‬الى معلم باالسود‪----‬شغلتين‬

‫اول شيء ‪ gastro esophageal junction‬مرتفعة اكثر والدكتور قال من الشكل مبين ‪barrett’s esophagus‬‬

‫بس منالحظ انه الشيء األهم ال ‪ longitudinal teat‬بال ‪ junction‬الي منسميه ‪ Mallory wises syndrome‬والي سببه‬
‫‪sever vomiting‬‬
‫ الي‬portal hypertension ‫الي سببهم‬---esophageal varices -----dilated enlarged veins ----‫الحظ بالصورة واحد‬
‫ غالبا‬liver cirrhosis or failure ‫بسببه‬

sever bleeding ‫ الي ينتج عنه‬rupture or ulceration ‫ يعمل‬eating hard rough foods ‫ او‬trauma ‫ممكن التعرض ل‬

normal ‫الصورة الثانية‬

‫ الي كنا نطلق‬esophagial mucosa (pinkish one) ‫ داخل‬gastric mucosa (red shiny) ‫الصورة الثالثة الحظ كيف ال‬
barrett’s esophagus ‫عليه‬

 An abdominal x-ray is an imaging test to look at organs and structures in the belly area.
Organs include the spleen, stomach, and intestines.

 When the test is done to look at the bladder and kidney structures, it is called a KUB
(kidneys, ureters, bladder) x-ray.

 Sometimes chest x ray is done for the patient to reveal esophageal abnormalities

 Barium swallow is a test that involves filling the esophagus, stomach, and small intestines
with a barium solution in preparation for an X-ray, to define the anatomy of the upper
digestive tract. Also known as upper gastrointestinal series.
Abdominal X-ray to expose just ( kidney,urinary bladder and uterus) for gall stones called

Kub

‫ عشان تبين األجزاء الي بتدخل فيها واالجزاء الي ما راح تبين فيها معناها ما‬contrast media ‫حكين انه ممكن نحقن مادة‬
obstruction ‫وصلتها يعني فيه‬

Barium‫المادة المستعملة على االغلب هي ال‬

Barium swallow----esophagus and stomach

If reaches the upper part of small intestine (duodenum) it is called Barium meal

⚫ Upright Chest X-Ray

− Look for intraperitoneal free gas (under diaphragm)

⚫ Fluid levels

− 3+ levels >2.5cm is abnormal

⚫ Small Bowel

− Central location, valvulae conniventes wall to wall

⚫ Large Bowel

− Peripheral location, folds part way across

Chest x ray---erect position----‫واقف‬

Abdomen x ray---supine position----‫متسطح على ظهره‬

‫ فيه شيء اسمه‬air fluid level ‫بحيث بكون السائل باالسفل والهواء باالعلى وببين السائل باللون األبيض والهواء اسود=فراغ‬

‫ اكثر من هيك بكون فيه على االغلب‬3 ‫ بالوضع الطبيعي الزم يكون عددها‬obstruction

‫ سم ففيه مشلكة‬2.5 ‫أيضا اذا كانت اكبر من‬

obstruction ‫مكان‬

‫ راح يكون بالمنتصف‬small intestine‫بحالة ال‬

 duedenum ‫ بفكر بال‬flat not folds ‫اذا كان العضو‬

folds jujenum or illume ‫اذا فيه‬

valvulae conniventes ‫ اسمها‬folds ‫ال‬

haustrations ‫ على األطراف وبكون فيها‬large intestine

Also look at:

⚫ Biliary Tree – for stones

⚫ Urinary Tract – for stones

− Pathway from Lumbar transverse processes → sacro-iliac joint → ischial spine

⚫ Bones

⚫ Soft tissues

‫علق انو ما ننسى نشيك على باقي الجزاء المذكورة باالعلى‬

air fluid level ‫الحظ هو انه هاي‬

 stomach bubble ‫وهاي أيضا‬

: ‫هيك الصافي‬
2 air fluid bubbles (not more than 3 so normal)

And they are not bigger than 2.5 CM

 1
Abdominal x ray

Is this a normal abdominal x-ray?

Yes, it is normal.
1)This is air fluid level
2)Stomach

‫ اﺧﺮ‬air fluid ‫وﻫﺬا اﻟﻤﻈﻬﺮ ﻫﻮ اﻟﻄﺒﻴﻌﻲ وﺑﻨﻼﺣﻆ اﻧﻪ ﻣﺎﻓﻲ‬

‫ﺑﺎﻟﺼﻮرة‬

Internet information
X-rays of the abdomen are important in diagnosing the
presence of small bowel obstruction. When obstruction occurs,
both fluid and gas collect in the intestine. They produce a
characteristic pattern called "air-fluid levels". The air rises above
the fluid and there is a flat surface at the "air-fluid" interface
 ‫‪2‬‬
‫‪Abdominal x ray‬‬

‫?‪What is the abnormality here‬‬

‫‪More than 3 fluid levels of more than 2.5cm is‬‬

‫‪abnormal – there may be obstruction of bowel‬‬

‫***ﺑﻨﻼﺣﻆ ال‪ air fluid level‬ﻋﻨﺪ ﻫﺬا اﻟﻤﺮﻳﺾ ﻣﻮﺟﻮدة ﻓﻲ اﻛﺜﺮ ﻣﻦ‬
‫ﻣﻜﺎن وﻛﻴﻒ ﺑﻨﺤﺪدﻫﺎ؟؟ ﺑﻜﻮن ﻓﻲ ﺧﻂ ﻓﺎﺻﻞ ﺑﻴﻦ اﻟﻬﻮاء واﻟﺴﻮاﺋﻞ )اﻟﺨﻂ‬
‫ﺑﺎﻟﻠﻮن اﻻزرق(ﺣﻴﺚ اﻟﻠﻮن اﻻﺳﻮد ﻫﻮ اﻟﻬﻮاء واﻻﺑﻴﺾ اﻟﺴﻮاﺋﻞ‬
‫وﻃﺒﻌﺎ ﻣﻬﻢ ﺑﻌﺮف اﻟﺴﺒﺐ ؟؟‬
‫اﻟﺴﺒﺐ ﻫﻮ ال‪intestinal obstruction‬‬
 ‫‪3‬‬
‫‪Abdominal x ray‬‬

‫?‪What is the abnormality here‬‬

‫‪Small bowel is dilated - Central location, valvulae‬‬

‫‪conniventes wall to wall across the bowel‬‬

‫ﻃﺒﻌﺎ اول اﺷﻲ ﺑﻨﻼﺣﻆ اﻧﻪ اﻟﺼﻮرة ﻣﻮ ﻃﺒﻴﻌﻴﺔ واﻧﻪ ﻓﻲ اﺟﺰاء ﻇﺎﻫﺮة ﻣﻦ‬
‫اﻻﻣﻌﺎء اﻟﺪﻗﻴﻘﺔ ﺑﺸﻜﻞ واﺿﺢ‬
‫ﻃﻴﺐ ﻛﻴﻒ ﺑﺪﻧﺎ ﻧﻌﺮف اﻧﻪ اي ﺟﺰء؟؟‬
‫ﺑﻨﻄﻠﻊ ﻋﻠﻰ اﻟﺸﻜﻞ واﻧﻪ اﻟﻬﺎ اﻟﺨﻄﻮط اﻟﻌﺮﺿﻴﺔ )ﻣﻮﺿﺤﺔ ﺑﺎﻟﺼﻮرة( وﻫﺬه‬
‫اﻟﺨﻄﻮط ﺗﺴﻤﻰ ‪valvulae‬‬
‫وﺑﺎﻟﺘﺎﻟﻲ اﻻﻧﺴﺪاد رح ﻳﻜﻮن ‪ jejunum‬وﺑﺎﻟﺘﺎﻟﻲ اﻟﺠﺰء ﻫﻮ ‪conniventes‬‬
‫ﻫﻮ اﻟﻲ ‪ dilation‬وﻫﺬا ﻣﻨﻄﻘﻲ ﻻﻧﻪ اﻟﺠﺰء اﻟﻲ ﺑﺴﻴﺮ ﻓﻴﻪ ‪jejunum‬ﺑﻌﺪ ال‬
‫ﻗﺒﻞ اﻻﻧﺴﺪاد ﻟﻤﺎ اﻟﺠﺰء اﻟﻲ ﺑﻌﺪ ﺑﻨﻜﻤﺶ‬
 4

Additional information )from internet)

The circular folds also, plicae circulares, or valvulae conniventes) are large
valvular flaps projecting into the lumen(from side to side )of the small intestine.
site :
starting from the second part of the duodenum, they are large and thick at the
jejunum and considerably decrease in size distally in the ileum to disappear
The haustra (singular haustrum) of the colon (large intestine)
 5
Abdominal x ray

What is the abnormality here?

Large bowel is dilated - Peripheral location (around the sides),

folds part way across the bowel
haustra and plicae circularis ‫ﻣﻬﻢ ﺟﺪا ﻧﻌﺮف اﻟﻔﺮق ﺑﻴﻦ‬
Haustra ‫ﻣﺎﺑﻦ=ﺗﻜﻮن ﻛﺎﻣﻠﺔ ﺑﺘﻜﻮن ع ﺟﺎﻧﺐ واﺟﺪ وﻫﻲ ﻟﻼﻣﻌﺎء اﻟﻐﻠﻴﻈﺔ‬
‫ ﻟﻼﻣﻌﺎء اﻟﺪﻗﻴﻘﺔ وﻛﺎﻣﻠﺔ ﻣﻦ اﻟﻄﺮف ﻟﻠﻄﺮف اﻻﺧﺮ‬plica ‫ﺑﻴﻨﻤﺎ‬
 ‫‪6‬‬
‫‪Abdominal x ray‬‬

‫?‪What is the abnormality here‬‬

‫‪Stones in the gall bladder‬‬

‫دواﺋﺮ ﺗﺸﺒﻪ اﻟﺤﺼﻰ ‪ 4‬ﻓﻲ اﻟﺠﻬﺔ اﻟﻴﻤﻴﻦ ﻋﻨﺪ اﻟﻜﺒﺪ ﺑﺎﻟﺘﺎﻟﻲ ﻫﻤﻪ اﻛﻴﺪ ﻓﻲ‬
‫اﻟﻤﺮارة‬
‫***واﻛﺪ اﻟﺪﻛﺘﻮر اﻧﻪ داﺋﻤﺎ ﺑﺲ ﻧﺸﻮف ﺻﻮرة ﻻزم اﻧﺤﺪد ﻧﻘﻄﺔ وﻧﻤﺸﻲ‬
‫ﻣﻨﻬﺎ ﺑﺤﻴﺚ ﻣﺎ ﻧﻨﺴﻰ اي اﺷﻲ ﻣﺜﻼ ﺑﻠﺸﻨﺎ ﻣﻦ اﻟﻨﻘﻄﺔ اﻟﺤﻤﺮاء ‪...‬‬
 7
Abdominal x ray

What is the abnormality here?

Stones in the kidney and a stone in the bladder

 8
Barium swallow

What is the abnormality ?

Achalasia
***barium swallow is a test that may be used to
determine the cause of painful swallowing, difficulty
with swallowing, abdominal pain, bloodstained vomit,
or unexplained weight loss. Barium sulfate is a
metallic compound that shows up on X-rays and is
used to help see abnormalities in the esophagus and
stomach.
‫***ﻓﻲ ﻫﺬه اﻟﺼﻮرة واﺿﺢ اﻧﻪ اﻟﺒﺎرﻳﻮم ﻣﺎ ﻋﺒﺮ ﻣﻦ اﻟﻤﺮيء اﻟﻰ اﻟﻤﻌﺪة‬
lower esophageal sphincter not dilated ‫واﻧﻪ‬
‫ﻣﻊ اﻟﻄﺒﻴﻌﻲ اﻧﻪ اﺗﻜﻮن ﻣﺮﺗﺨﻴﺔ ﻟﺘﺴﻤﺢ ﺑﻤﺮور اﻟﻤﻮاد‬
 9
Chest x ray

What is the abnormality ??

Hiatal hernia

***we find air fluid level at heart level which is

indicator for hernia in diaphragm lead to projection of
small part of stomach .
***notice :air fluid level which is gastric bubble here
and its normal
 10
Case study

Chief Complaint: 62-year-old man with bleeding per mouth

History: Vincent Miller, a 62-year-old accountant, has had a "drinking problem" throughout most of his adult life. He
drinks about a half-case of beer each day(he drinks 3 ( ‫ﻣﻦ اﺻﻞ‬6‫) ﻋﻠﺐ‬. He has lost several jobs over the years for
drinking at the workplace or showing up for work drunk
liver cirrhosis lead to: ‫ﻣﻦ ﻋﻨﺪ ﻫﺬه اﻟﻤﻌﻠﻮﻣﺎت ﻣﻤﻜﻦ ﻧﺒﺪأ ﻧﻌﻤﻞ اﻟﺘﺸﺨﻴﺺ اﻧﻪ ﻫﻮ ﺑﺸﺮب ﻛﺤﻮل ﻛﺘﻴﺮ وﺑﻠﺶ ﻳﺼﻴﺮ ﻋﻨﺪه ﻧﺰﻳﻒ ﻓﻤﻤﻜﻦ ﻳﻜﻮن‬
esophegal varisis then bleeding or due to vomiting may have mallory weiss syndrome
. He lost his driver's license for drunk-driving, and his drinking has placed a considerable strain on his marriage. He has
tried several self-help programs as well as Alcoholic's Anonymous, all with little success. He has been hospitalized on
several occasions over the years. Vincent has a severe tremor in his hands (probably a result of excessive alcohol
intake), which makes it very difficult for him to use a spoon, fork, and knife to eat. It's your first day on the job as an
occupational therapist, and you are consulted by his physician to see if there is any way to help Vincent use eating
utensils. Not knowing anything about him, you open up his past medical records, which, incidentally, are quite thick.
 11
Case study

First Hospitalization:
You note that Vincent was hospitalized at age 32 with a complaint of vomiting up blood after a drinking binge that lasted seven
days and was marked by excessive and repeated vomiting episodes. The vomitus was bright red.
Endoscopy was done and the image is as below
alcoholic hepatitis ‫ﻏﺎﻟﺒﺎ ﺑﻜﻮن ﻋﻨﺪه‬
‫ اﻧﻪ‬bright red ‫***ﺑﺲ اﻟﻤﻬﻢ ﻫﻮ ﻟﻮن اﻟﺪم ﻻﻧﻪ ﻟﻮ اﻟﺪم ﻧﺰل اﻟﻰ اﻟﻤﻌﺪة ﺑﻜﻮن ﻟﻮﻧﻪ اﺳﻮد و ﻓﻲ ﺣﺎل ﺿﻞ اﻟﺪم ﻳﻮﻣﻴﻦ ﻓﻲ اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ او اﻛﺜﺮ ﺑﺮﺿﻪ ﺑﺘﺤﻮل ﻟﻼﺳﻮد وﺑﺎﻟﺘﺎﻟﻲ ﻣﻌﻨﻰ اﻧﻪ‬
‫ﻣﺎﺻﺎر اﺷﻲ ﻣﻦ اﻟﺤﺎﻻت اﻟﺴﺎﺑﻘﺔ وﻣﻤﻜﻦ ﻳﻜﻮن اﻟﻨﺰﻳﻒ ﻣﻦ اﻟﺠﻬﺎز اﻟﺘﻨﻔﺴﻲ‬
malllory wessi syndrome ‫ ﺑﺎﻟﻤﺮيء ﻓﻐﺎﻟﺒﺎ ﻋﻨﺪه‬tear ‫***ﺑﻼﺣﻆ اﻧﻪ ﻋﻨﺪه‬
‫ ﺑﺎﻟﺘﺎﻟﻲ اﻟﻤﺮﻳﺾ ﺑﻜﻮن‬mediastinum ‫وذﻛﺮ اﻟﺪﻛﺘﻮر اﻧﻪ ﻣﻤﻜﻦ ﻫﺬا اﻟﺘﻤﺰق ﻳﻮﺻﻞ اﻟﻰ‬
,Boerhaave syndrome‫ﻋﻨﺪه‬
sever infection in mediastinum ‫ﻫﻲ ﺗﻌﺮﻳﻔﻬﺎ وﻫﻲ ﺧﻄﻴﺮة ﺟﺪا ﻣﻤﻜﻦ ﺗﻌﻤﻞ‬
a transmural perforation of the esophagus, should be distinguished from Mallory-Weiss
syndrome, a nontransmural esophageal tear that is also associated with vomiting.
Because it is often associated with emesis, Boerhaave syndrome usually is not truly
spontaneous
Questions:
1. Why was the blood bright red, rather than the color of "coffee "? ‫ﺟﺎوﺑﻨﺎه ﻓﻮق‬
2. Based upon your knowledge of the vomiting reflex, why might severe vomiting tear the mucosa?
3. What is most likely the diagnoses?
 ‫‪12‬‬

‫‪Vomiting reflex :‬‬

‫ﻛﻴﻒ ﺑﺤﺪث ﺑﺴﻴﺮ ﻓﻲ ﺷﺪ ﻓﻲ ﻋﻀﻼت اﻟﺒﻄﻦ ﺑﺤﻴﺚ ﺗﺤﺎول ﺗﺪﻓﻊ ال‪ vomitus‬و ال‪ peristaltic waves‬ﺑﺘﺴﻴﺮ‬
‫ﺑﺎﻟﻌﻜﺲ وﺑﻜﻮن اﻟﻀﻐﻂ ﻋﺎﻟﻲ ﺟﺪا ﺑﺤﻴﺚ ﻳﺪﻓﻊ اﻟﻤﻮاد ﻣﻦ اﻟﻤﻌﺪة ﻟﻠﻔﻢ وﺑﻨﻔﺲ اﻟﻮﻗﺖ اﻟﻤﻔﺮوض ﻳﺤﺪث‬
‫‪ relaxation of lower esophageal sphincter‬ﺑﺲ ﻋﻨﺪ اﻟﻨﺎس اﻟﻲ ﺑﻜﻮﻧﻮا ﺑﺸﺮﺑﻮا اﻟﻜﺤﻮل ﺑﻜﻤﻴﺎت ﻛﺒﻴﺮة‬
‫ﻣﺎ ﺑﺴﻴﺮ‪ relax‬ﺑﺎﻟﺘﺎﻟﻲ ‪tears of esophagus‬‬
‫وﻓﻲ اﺳﺒﺎ اﺧﺮى ﻣﻤﻜﻦ ﺗﺆدي اﻟﻰ اﻧﻪ ﻣﺎ ﻳﺤﺪث ال‪ relaxation‬ﻣﺜﻼ ‪ bulimia nervosa‬اﻟﻲ ﻫﻴﻪ ﻧﺎس ﺑﻮﻛﻠﻮا‬
‫ﻛﻤﻴﺎت ﻛﺒﻴﺮة ﺑﺲ ﻋﺸﺎن ﻣﺎ ﻳﺰﻳﺪ وزﻧﻬﻢ ﺑﺴﺘﻔﺮﻏﻮا ﺑﺤﻴﺚ ﺑﺤﻄﻮ اﺻﺎﺑﻌﻬﻢ ﺑﺪاﺧﻞ اﻟﻔﻢ اﻟﻰ اﻟﺤﻠﻖ‪ ...‬وﻫﺬا ﺧﻄﻴﺮ‬
‫ﻻﻧﻪ ﻣﻤﻜﻦ ﻳﺆدي اﻟﻰ ‪tear‬‬
 13
Case study
Answers
1. The bright red color of the vomitus indicates that the blood either didn't enter the acidic environment of the stomach, or didn't
spend much time in the stomach. Blood that remains in the stomach for longer periods becomes dark and hardens into pieces that
resemble coffee grounds, hence the term "coffee ground emesis.“
2. The following events occur as part of the vomiting reflex:‫ﻣﻬﻤﺔ رﺟﻊ ﻋﺎدﻫﺎ ﻫﻮن‬
a) The individual inhales deeply and holds the diaphragm in the flattened and contracted position. In this position, the diaphragm pushes
against the stomach and raises intra-abdominal pressure.
b) The glottis closes to prevent vomitus from entering the respiratory tract.
c) The abdominal wall muscles contract (i.e. the "bearing down" or Valsalva maneuver), further increasing intra-abdominal pressure and
therefore increasing external pressure on the stomach.
d) The lower esophageal sphincter (also called the cardiac sphincter) relaxes to allow the stomach contents to enter the esophagus and be
propelled to the mouth.
e) The soft palate elevates to close off the opening into the nasal cavity.
Thus, the act of vomiting greatly increases the intra-luminal pressure in the stomach and esophagus. This, coupled with the fact that the
vomitus is very acidic, causes irritation of the lower esophageal lining. In instances of severe, repeated bouts of vomiting, the esophageal
mucosa may actually tear. This phenomenon is called a Mallory-Weiss tear.
3. The hospital chart lists a diagnosis of "Upper GI bleed" due to a Mallory-Weiss tear. "Mallory-Weiss tear is defined as "a longitudinal
tear in the mucosa at the gastroesophageal junction -- i.e. in the area of the lower esophageal sphincter -- caused by repeated
vomiting."
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Case study

Second Hospitalization
At age 41, Vincent entered the hospital with complaints of a high fever, nausea, loss of appetite, and a dull, continual
pain in the epigastric area radiating to the left side of the back. In addition, he had diarrhea of a particularly foul
odor and yellow color . He had also lost 15 pounds over the last month and a half. Unfortunately, the page in the
chart is torn, so you cannot read the diagnosis! But the following lab results will help you figure it out
Amylase is elevated
Lipase is elevated
CBC reveals elevated WBC and low Hct
ALT is slightly elevated
LDH is elevated

Questions:
1. Excessive exposure to alcohol can cause inflammation of certain digestive organs, such as the stomach.
Inflammation of which organ(s) might be causing Vincent's back pain?
2. Based upon the location of this pain, would you guess that the organ in question is a retroperitoneal organ or an
organ attached to the abdominal wall by a broad sheet of mesentery? Explain your answer.
3. Based upon the function of the organ in question, what is causing the "steatorrhea" and weight loss?
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‫ و اﻟﺴﻼﻳﺪ اﻟﻠﻲ ﺑﻌﺪه ﻓﻲ إﺟﺎﺑﺎت اﻟﺪﻛﺘﻮر‬،‫ﺑﻬﺎد اﻟﺴﻼﻳﺪات رح ﻧﺸﺮح اﻻﺟﻮﺑﺔ زي ﻣﺎ ﺷﺮﺣﻬﻢ اﻟﺪﻛﺘﻮر ﺑﺎﻟﻔﻴﺪﻳﻮ‬
Q1: radiation to the back‫ ﺻﺎرﻟﻪ‬epigastric pain ‫ ﻫﻮ اﻧﻪ ال‬back Pain‫اوﻻ ال‬
‫و ﻛﻮﻧﻪ اﻟﻤﺮﻳﺾ ﻋﻨﺪه‬diarhhia with foul smell ‫ﻓﺎﻟﺴﺒﺐ ﺑﻜﻮن‬mal absorbtion ‫اﻟﻠﻲ ﺑﺤﺪث ﻧﺘﻴﺠﺔ‬
alcoholic pancreatitis‫( وﺗﺤﺪﻳﺪا‬pancreatitis) ‫اﻟﺘﻬﺎب ﻓﻲ اﻟﺒﻨﻜﺮﻳﺎس‬
The most important causes of pancreatitis are:
1- alcohol, 2-gall stones(it closes thr pancreatic duct and cause inflammation
Q2: Retroperitoneal (radiation of pain to the back‫)و ﻫﺬا ﺳﺒﺐ ﺣﺪوث ال‬
Q3:the exocrine function of the pancrease is digestion of protiens and fats, so pancreatitis
cause problem in their digestion and they remain in the digestive tract causing osmotic
pressure pulling water from the body to the digestive track Causing diarrhia with foul
smell and diffcult to flush which is “steatorrhia”
and the wight loss because of the malabsorbtion of protiens and fats so they remain on
the digestive tract.
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Case study

Answers
1. Chronic exposure to alcohol can cause pancreatitis - - i.e. inflammation of the pancreas.
2. Since the pancreas is a retroperitoneal organ, the dull, throbbing pain associated with pancreatitis is often felt in
the back. It is therefore likely that Vincent is suffering from alcohol-induced pancreatitis. The destruction of
exocrine cells in the pancreas reduces this organ ability to secrete digestive enzymes and HCO3- ions into the
duodenum during meals. Consequently, many of the nutrients in Vincent's meals will never be completely digested,
and therefore never absorbed into the bloodstream. Vincent will slowly lose weight due to this malabsorption
syndrome.
3. Since many of the nutrients Vincent ingests during a meal pass through the intestines unabsorbed, they osmotically
draw water from the bloodstream into the intestinal lumen, causing an "osmotic diarrhea." The high fat content of
the stool gives it a foul odor and yellowish color - - a condition called steatorrhea. The inability of Vincent to absorb
the nutrients of his meal will cause him to slowly lose weight. This malabsorption syndrome can now be treated with
the ingestion of pancreatic enzymes with each meal.
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Case study

Third Hospitalization

As you read on, you note that Vincent was hospitalized again at age 49 with dull pain in the right,
upper quadrant of the abdomen, intermittent fever of 3 weeks duration, and a yellowing of the skin
and the whites of the eyes.
Lab results reveal:
Elevated CRP

(AST) level is moderately elevated

(ALT) level is in the reference range

(ALP) level is mildly elevated

(GGTP) level is elevated markedly

Bilirubin level is elevated

Pt is prolonged
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Case study

Answers
1. alcohol-induced hepatitis

2. With excessive intake of alcohol, the liver switches over from the use of fats and carbohydrates as its primary
"fuel" to the use of alcohol as its primary fuel. This can lead to excessive production of lactic acid, which, in
turn, can cause inflammation of the liver tissue. The liver occupies the majority of the right upper quadrant
of the abdomen, and thus pain of liver origin is often felt over the surface of the abdomen's right upper
quadrant. As alcohol-induced hepatitis progresses, the unused fat accumulates in the liver, causing the organ
to change in color from a dark, reddish brown to a yellowish color that resembles nutmeg (hence the terms
"nutmeg liver" or "fatty liver"). In the final stages, the liver tissue can be destroyed by scar tissue (i.e.
cirrhosis of the liver).

3. The right and left hepatic ducts emerge from the undersurface of the liver and combine to form the common
hepatic duct. The common hepatic duct, in turn, merges with the cystic duct (coming from the gallbladder) to
form the common bile duct. Finally, the common bile duct courses downward toward the pancreas, where it
merges with the main pancreatic duct to form the ampulla of Vater, the end of which opens into the
duodenum of the small intestine. A small ring of smooth muscle called the sphincter of Oddi regulates the
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Case study

4. A gallstone expelled from the gallbladder can be force by peristaltic contractions down through the cystic and
common bile ducts. If it gets lodged and stuck near the ampulla of Vater, it could partially or completely block not only
the flow of bile from the liver and gall bladder into the duodenum but also the flow of the bicarbonate-rich fluid and
digestive enzymes from the pancreas into the duodenum. This may cause bile (a powerful lipid-emulsifying agent) to
regurgitate into the pancreas and cause destruction of the tissue. Furthermore, the pancreatic enzymes building up in
the pancreas may be converted to their active forms and begin to digest the pancreas, itself. Thus, someone with a
gallstone lodged in the ampulla of Vater is at risk of developing severe damage to the pancreas and pancreatitis.

5. If Vincent has a gallstone obstructing the flow of bile, he may develop "obstructive jaundice." Bilirubin, a breakdown
product of the hemoglobin in red blood cells, is primarily excreted from the body through the bile. If the flow of bile is
blocked, it is difficult to excrete bilirubin. Thus, bilirubin levels may rise in the bloodstream, causing the typical
yellowish appearance of the skin and eyes known as jaundice - - in Vincent's case, "obstructive" jaundice because the
jaundice is due to the obstruction of bile flow.
Third hospitalization
痐ᅓ Ềఔᅓ 痐Ềఔ ϴ ఔఔ ᅓ痐ge 痐Ềఔ 痐ఔ Ềఔ 痐ఔ⺁ ఔg Ề⺁ ఔ ఔe eỀఔ
(jundice 痐ఔ⺁ ఔఔ⺁ ఔఔe Ềఔ⺁ ⺁( ఔỀᅓ ⺁e g⺁ ఔ ⺁
1-↑CRP---->related for systemic inflamation
Ϊ⺁痐 ఔỀ⺁ 痐ఔ ϴ ỀỀ⺁ 痐⺁ ϴ
↑AST or ALT---->indicated for liver Dz
↑ALP or GGT---->indicated for biliary system Dz

痐ᅓ 痐ఔi e Ϊఔ⺁ ᅓ AST or ALT 痐ᅓ 痐ఔi e Ϊఔ⺁ 痐⺁ ⺁ Ềఔe eỀఔ ⺁ ⺁

biliary system 痐ᅓ ϴỀϜỀఔe eỀ痐ఔALP or GGT

⺁e ఔఔϴఔ ᅓ direct or indirect eỀe Ϊఔ 痐⺁ ᅓ ఔi ⺁ Ϊఔ⺁ ᅓ⺁ ϴ ϴఔe⺁

Ϊఔᅓ ΪϴỀఔe 痐⺁ ఔఔ⺁ gall stones 痐ϴఔ痐 Ϊఔ⺁ ⺁e alϜఔᅓ Ềఔ η痐ϴỀఔe
ϴ⺁ ᅓ⺁ ϴ ϴఔe ఔ ϴఔ biliary system 痐ᅓ ①ఔᅓ 痐⺁ ᅓconjugation Ềఔ⺁
Ϊఔe
right upper quadrant lope 痐ᅓ ఔ⺁ 痐ఔ⺁ ఔ⺁ e eỀఔ ⺁ Ềఔe⺁
ΪϴỀఔe Ϊఔ⺁ Ϊ e
- ᶀ⺁ Ϊఔ⺁ 痐ఔ⺁痐ϋ⺁ Ϊ⺁ a⺁ ỀỀ⺁⺁
Cholecystitis(inflammation of gall bladder),pencreatitis(due
to blockage of ampulla of vater),block of duodenum

Ϊఔ⺁ Ề⺁ Ềఔ ⺁ఔ ϴ Ềఔ⺁ alcoholic liver disease ᅓ ఔఔ痐ᅓ e ϗi e

ALT e 痐ఔόe ⺁e 痐ఔi e ఔόAST 痐ᅓ 痐ఔi e ⺁ Ềఔe
Fourth hospitalization
sever bright bloody vomiting ఔϜఔ Ềఔe Ề⺁ ⺁ Ềఔe eỀఔ
ఔᅓ痐ఔ ⺁e ఔఔϴi ఔ Ềఔ痐ᅓ 痐ఔ⺁⺁ ϴ⺁ ఔఔ⺁ ᶀ Ề痐⺁ ϐϋఔe Ϊఔ⺁⺁
ϴϴఔe ఔఔ⺁ ϴఔ ηe e 痐⺁ Ϊఔᅓ ఔ痐 ఔe 痐ఔ

①ఔ⺁ ①ఔ⺁ ①ఔ⺁ ①⺁⺁ ①⺁ 香⺁①⺁⺁ rupter esophegeal varices ఔఔm

①⺁ ①⺁ ఔm ①ఔఔ ⺁ఔ ⺁⺁ Θఔఔ ①⺁ ϫ ⺁ ϋ ήఔ 香ఔ① ①① 香 ①⺁⺁ ①ఔ ①⺁
①⺁ ఔ ⺁ ꠀ① 香①ఔఔ Ềఔ varices ①ఔϋ ఔ① ①⺁ aΘiఔఔ ⺁ఔΘ⺁ఔỀ⺁ Ề
ỀỀ⺁⺁ Ềఔ ①⺁

Portal hypertension& cirrhosis ఔ ఔ⺁ ఔఔᅓvarices e 痐ఔ 痐ఔϴΒ⺁

clotting factors Ϊఔ⺁ 痐Ềఔ ⺁ ϐఔϜᅓ 痐⺁ Ϊఔ⺁ ΪϴỀఔe ⺁ ⺁ Ềఔe eỀఔ⺁
i ⺁Ϊᅓ ①ఔ⺁ ϋᅓ Ềఔ
( ỀỀ⺁ Ϊ⺁ϗ ఔ痐ᅓ aఔe
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Case study

Fourth Hospitalization

At age 58, Vincent was rushed to the emergency room with severe vomiting of bright red blood. On
examination, he had a blood pressure of 60 mmHg / 30 mmHg. The bleeding and vomiting started
abruptly while Vincent was eating some hard, dry French bread. An endoscope (i.e. a flexible tube
equipped with a camera) was placed down Vincent's esophagus and the following image was taken

Questions:

What is most likely the diagnosis?

What are esophageal varices?
2. Where are esophageal varices typically located?
3. On the hospital chart you see two other "secondary diagnoses" listed:
(1) cirrhosis of the liver, and (2) portal hypertension.
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Case study

Answers:
Esophageal varices

Esophageal varices are distended veins in the submucosa of the esophagus. Enlargement of
these veins causes them to protrude out into the esophageal lumen, where they are at risk of
tearing if Vincent swallows food that is particularly hard in texture.

Esophageal varices are usually located in the lower end of the esophagus, where veins of the
portal circulation (i.e. veins ultimately draining blood through the portal vein of the liver)
anastomose with veins of the systemic circulation (i.e. veins ultimately draining blood into the
superior and inferior venae cavae).