CHAPTER 41 : Problems of The mouth
- cause the gingivae to separate from the tooth
Tooth and Gum Disease
● Progressive tooth loss
- used to be considered a virtually Inevitable
consequence of aging
● Primary Goal Tooth Loss
- Tooth maintenance
- preservation of natural teeth
● Tooth Decay
- far the most common problem affecting the
teeth
● Plaque Formation
- most important factor in tooth decay
● Other factors of tooth decay
- familial tendency
- poor oral hygiene
- poor health
- diet high in simple or refined sugar
● Periodontium
- the tissue that surrounds and supports the
teeth
● Disease of the Periodontium
- most common cause of tooth loss in adult after
age 50
● Bacterial Plaque
- most important contributor to the problem
● Other Factors of Periodontium
- dental malocclusion
- caries, dietary deficiency
- systemic disease (diabetes)
PATHOPHYSIOLOGY
● Dental Plaque
- a soft, colorless mass composed of
proliferating bacteria that adheres to the teeth
- secretes acid
- collect on the teeth within 2 hrs of eating
● Acids produce by Bacteria
- slowly destroy the enamel and dentin of the
teeth, creating cavities
● Cavities
- visible evidence of decay
● Carbohydrate
- stimulates bacterial acid production
● Simple Sugars
- have greatest effect
● Gingivitis
- earliest form of periodontal disease
- characterized by reddened gums. swelling and
easy bleeding
● Inflammation
surface, forming pockets
● Progressive Gingivitis
- result in receding gums, resorption of alveolar
bone, and loosening of teeth
● Common Early Sign of Gingivitis
- bleeding of the gums with normal tooth
bruising
- no pain
COLLABORATIVE CARE MANAGEMENT
● Prevention
- most appropriate management strategy for
both dental decay and periodontal disease
● Fluoride
- makes tooth enamel more resistant to acids
- widely available in toothpaste, dental rinses
and mouthwashes
● Sealants and Bonding preparations
- can be applied in childhood to increase tooth
resistance to decay
● treatment of periodontal disease
- removal of decayed tooth structure
- replacement with restorative barriers
● treatment for progressive gingivitis
- scaling or root planning to control or correct
the problem
PATIENT /FAMILY TEACHING
● mainstay of prevention for tooth and gum disease
- Good oral hygiene with frequent brushing and
regular flossing
● Facilitate Early Identification and Intervention
- Regular check-up
- professional cleaning
● Standard Recommendation
- Restricting the amount of simple sugar in the
diet
● Vitamin C
- believe to reduce plaque
MOUTH INFECTION
● Oral Infection
- also occur secondary to vitamin deficiencies,
other systemic disease or treatment or local
trauma or stress
● Common Examples of Oral Infection
1. Aphthous stomatitis
- produces well circumscribes, shallow
ulcers (canker sores) that are often
covered with a grayish white or yellow
exudates on the soft tissues of the
mouth
 - Aphthous Ulcers Are chronic problem
2. Herpes Simplex
1. viral infection that produces
characteristic blisters referred to as
cold sores or fever blisters
3. Acute Necrotizing ulcerative gingivitis
- also called trench mouth
- an acute inflammatory gum disease
caused by a tremendous proliferation
of normal mouth flora, such as
4. Candidiasis (thrush)
5. Glossitis
- infection in the tongue
6. Parotitis
- inflammation in the salivary and
parotid gland
7.
CHAPTER 42 Stomach and Duodenum Problems ● Diarrhea
- common symptom due to lack of
the pancreatic lipase needed for
I. Dyspepsia
fat digestion.
● variety of common upper abdominal symptoms
● radioimmunoassay measurements of
that may accompany a range of
high serum gastrin levels.
gastrointestinal (GI) disorders,
● symptom than a diagnosis,
B. ACID SECRETION.
II. Gastritis
● Gastric acid (and intrinsic factor)
● Aspirin, even in low doses, and other
(NSAIDs) are the most common causes of - secreted by the parietal cells of the
reactive gastritis. fundus of the stomach in response to
● Acute gastritis ○ Gastrin
- predominandy an erosive process ○ Acetylcholine
and is believed to be responsible for
○ histamine
up to 10% to 30% of all episodes of
GI bleeding. ● H2 receptors
● Helicobacter pylori ○ secretion of hydrochloric acid (HCI)
- most common cause of chronic ● Acid oversecretion
gastritis
- primary factor contributing to ulcer
● Acute gastritis development
- develops when the protective C. Mucosal Defenses
mechanisms of the stomach mucosa
D. EFFECTS OF HELICOBACTER PYLORI
are overwhelmed by bacterial toxins
INFECTION
or irritating substances.
● H. pylori
● Chronic gastritis
- a gram-negative bacterium
- involves primarily the fundus and
with a spiral shape
antrum of the stomach.
○ Produce urase
● Reduce dietary fat
- neetralize acid and
● Eating smaller and more frequent meals,
has toxic effect
● avoiding alcohol and smoking.
○ releases cytokines that
● Stress management cause chronic gastritis.

III. Peptic Ulcer Disease E. Effects oF NSAIDS.

● acid oversecretion ● inhibition of cyclooxygenase (COX),
- the primary cause ○ Primary adverse effect
● diet modification and acid neutralization ● Low prostaglandin =
● Causes ○ decreased mucus and bicarbonate
secretion
○ H.pylori
○ decreased mucosal blood flow
○ NSAID
○ failure to inhibit gastric acid secretion
○ Smoking
○ prevents the formation of the mucous
○ Alcohol
“cap”
● Diagnosis
○ Pain
○ Crater at mucosa
- classic symptom associated with
A. ZOLLINGER-ELLISON SYNDROME. PUD,
● caused by a gastrinoma (gastrin-producing ○ Pain that occurs at night and awakens
tumor), the person from sleep is a common
symptom of duodenal ulcers
○ found in the noninsulin-producing islet
cells of the pancreas.
○ overstimulates gastric acid secretion F. COMPLICATIONS OF PUD
● Rare a. Hemorrhage
● Men ● Aging
- clearly the most critical risk
factor
 ● Aspirin and NSAID use IV. Stress Ulcers
- considered the most common predisposing ● major factor that causes stress ulceration is a
factors for bleeding. loss of ability to maintain the integrity of the
gastric mucosa.
● H. pylori N
● epithelial cells of the mucosa
- NOT bleeding
- extremely sensitive to hypoxia,
● Alcohol
● Mucosal resistance
- exacerbates the effects of NSAIDs and
aspirin. - believed to be the key.
● hematemesis ● Cushing’s ulcer and Curling’s ulcer,
- (vomiting of blood) = proximal upper GI site of - which are associated with massive
bleeding. increases in acid output, often
exceeding 3 to 4 L/day.
● Dark coffee ground emesis = long in stomach
● Stress ulcer lesions
● Bright red bleeding
- tend to be shallower than standard
- indicates a recent onset.
peptic ulcers and develop in multiple
● Melena sites rather than as a single well
defined lesion.
- refers to the passage of black, tarry,
foul-smelling stools ● Classic presentation of stress ulcers
● Hematochezia - development of painless GI
bleeding
- represents the passage of bright red blood
from the rectum
● Rapid assessment and resuscitation V. Cancer of the Stomach
- the keys to successful treatment of upper GI ● Causes
bleeding.
○ H.Pylori
● Most common sign
■ major carcinogen for gastric
- hematemesis, cancer
● Shock ○ High nitrate content in soil and water
- will not occur until blood loss approximates ○ diets high in smoked and salt-preserved
40% of the total volume, foods
○ Nitrates and nitrites in foods
b. PERFORATION. - reduced ro nitrosamines in the body,
● complication of therapeutic endoscopy - which can trigger a cascade of
deoxyribonucleic acid (DNA)
● Older adult presentation are minimal
changes that lead to cancer.
● classic clinical picture of ulcer perforation
○ first-degree relative with
○ severe, sharp abdominal pain
○ Smoking
○ rigid abdomen with rebound
○ male
Tenderness;
● Diet
○ tachycardia, tachypnea, and
diaphoresis ○ Refrigerate; low temperature
○ decreased bowel sounds ○ Fresh
● Lavage - cleaning ○ avoiding spicy and irritating foods
● Gavage - feeding ● Meds
c. OBSTRUCTION. ○ Aspirin
● Diagnosis ● Manifestations
○ Aspiration of gastric contents ○ Rapid weight loss
○ X-ray -
common symptom of gastric
cancer
● Collaborative (1212-1214)
○ High COX 2
● H. pylori infection
● Complication
- now recognized as the main
○ Cachexia is a common complication and
determinant of ulcer relapse,
is not easily treated.
● patients are simply encouraged to eliminate or
● Chemotherapy
restrict specific foods that cause discomfort
until healing occurs.
 - mainstay of treatment for ● Primary malabsorption disorders
nonresectable tumors,
○ GLUTEN-SENSITIVE ENTEROPATHY (CELIAC
● The only potentially curative treatment for gastric DISEASE).
cancer is surgical resection.
■ Familial
● CoMPLicaTiONS of Gastric SURGERY.
■ permanent intolerance to fractions of
○ Dumping Syndrome. gluten (wheat protein).
■ rapid entry of food boluses directly into ■ Diarrhea
the upper small intestine that have not
- primary symptom
first undergone the usual breakdown and
dilution in the stomach.
■ Prevention ○ DISACCHARIDE MALABSORPTION.
- most effective means of controlling ■ congenital lactase deficiency
dumping syndrome
- most common form of genetic
○ Vitamin B12 Deficiency. deficiency syndrome in humans.
■ 100- to 200-mg monthly injection of ■ Lactose intolerant
vitamin B,» prevents the deficiency.
○ Short-Bowel SYNDROME.
○ Malabsorption and Duodenal Reflux.
■ Diarrhea and steatorrhea
■ Bile acids
- predominant symptoms
- believed to be the primary cause.
■ Inflammatory bowel disease,
■ surgical bypass - for severe particularly Crohn’s disease, is the
major cause
■ Fat malabsorption
■ Impair absorption of both calcium and
iron. B. Protein-Calorie Malnutrition
● Negative nitrogen balance
VI. Nausea and Vomiting - occurs when more nitrogen
(which is an end product of
● Slow or no gastric tone or peristalsis
amino acid breakdown) is
● Vomiting center excreted than is ingested via
dietary proteins;
○ At the medulla
● Albumin
○ Stimulated by vagus and sympathetic
- major protein synthesized
● chemoreceptor trigger zone (CTZ),
by the liver,
○ Indirect stimulation
● Diet
● Gastrointestinal serotonin is synthesized by
○ High-calorie
enterochromaffin cells
○ high protein
○ Activates 3(5-HT3)
● dehydration and metabolic alkalosis, with loss
of potassium, chloride, and hydrogen ions.
● Diet
○ limit intake of creamy and milk-based
liquids and foods
○ Lean poultry
- usually the best tolerated
source of protein

VII. Problems of Nutrition and Absorption

A. Malabsorption
● failure to assimilate one or more
essential ingested nutrients.
● inadequate absorption of fat, protein,
or carbohydrates.
● Fat malabsorption
- most common problem,
● classic sign of fat malabsorption
- steatorrhea,
 CHAPTER 43 INTESTINAL PROBLEMS
● diagnosis
- based primarily on the consistency of the
Functional Bowel Disorders
stool
Constipation
● Diarrhea
● voluntarily controlled by contraction of the external anal
- classic sign of gastrointestinal (GI) disease a
sphincter
● three times a day to once every 3 or more days.
● Acute diarrhea
● older adults.
○ most frequent
○ caused by infectious agents,
● Causes:
○ Endocrine and neurologic diseases (chronic
● Raw and undercooked and undercooked chicken
constipation)
- two of the prime sources of infection
■ diabetes,
● Eggs
■ hypothyroidism,
- salmonella
■ multiple sclerosis,
-
■ Parkinson's disease
● Campylobacter jejuni
○ opioids,
- considered the leading cause of
○ Anticholinergics,
bacteria-induced diarrhea;
○ anticonvulsants and
- most hens
○ calcium channel blockers.
○ physical inactivity,
● Contamination of food preparation surfaces
○ stress,
- prime source of infection.
○ Dietary changes,
○ lack of fluids
● Large-volume diarrhea
○ failure to respond to the urge to defecate.
- caused by a hypersecretion of water and
electrolytes by the intestinal mucosa.
● Decreased motility and retention
● The longer the feces remain in the colon, the greater
● Peristalsis is increased
the amount of water resorbed and the drier the stool
● Transit time
becomes-
- through the intestine is significantly
decreased.
● after meals, particularly breakfast
- urge to defecate
● Manifestation:
○ Severe abdominal cramping,
● habitual constipation =
○ tenesmus (persistent spasm) of the anal area,
○ decreased intestinal muscle tone
○ abdominal distention,
○ increased use of Valsalva’s maneuver
○ borborygmus (loud bowel sounds)
○ increased incidence of hemorrhoids.
● Mild diarrhea
● Chronic constipation
○ losses of sodium and potassium
- fecal impaction
○ metabolic alkalosis.
● Dietary fiber
● Severe diarrhea
- increases the water content of the stool and
○ Dehydration
promotes colonic Motility through bacterial
○ Hyponatremia
degradation,
○ hypokalemia,
○ loss of large amounts of bicarbonate =
● Nonabsorbable disaccharides
metabolic acidosis
- (e. g,sorbitol or lactulose)
● Persistent diarrhea
● chronic use of stimulant laxatives
- skin breakdown in the perianal region.
- avoided if possible.
● serious outcome or death
- usually related to dehydration,
● Initiation of a plan to prevent constipation
- should be a priority for any patient on bed rest
● Clear liquids
or receiving frequent doses of opioids.
● Low fiber diet
● limit highly refined foods
● rich in sodium and glucose.
● Bran
● Skin ointments and barriers (e.g.. zinc oxide)
- may be used as a supplement in a limited
- reapplied as needed after each episode of
way.
diarrhea.
● drink at least 2 L of fluid daily
● Sitz baths
● bulk-forming laxatives
● Store eggs in the refrigerator,
● Avoid the regular use of harsh laxatives or any type of
- use within 3 to 5 weeks
enema.
● Hard Boiled eggs within a week.
Diarrhea and Foodborne Illness
● refrigerator is 40° F or colder
● increase in stool number,
● Freezer is 0° F or colder.
● more fluid consistency,
 ● Use a meat thermometer for cooking large pieces of ○ relief of discomfort with defecation.
meat. ○ excessive gas
● Avoid slow cooking ○ bloating
● Psychological stress
- exacerbates symptoms.
Fecal Incontinence ● Rome I, Rome Il, and Manning criteria.
● Involuntary release of stool. ● Limiting gas producing foods
● Causes: ● Fiber
○ relaxation of the external or internal anal ● Antidiarrheal agents and cholestyramine
sphincters - for diarrhea
○ interruption of voluntary control of defecation ● bulk-forming laxatives
○ impaired anal sensation, - for constipation,
○ structural damage ● antispasmodics
- for pain
● vaginal delivery = ● Tricyclic antidepressants
○ Perineal relaxation - severe pain.
○ damage to the anal sphincter
● Rectum ● Tegaserod (5-HT4, serotonin)
- stores the feces until defecation. - receptor agonist - short-term treatment of
women with constipation predominant IBS. =
● external sphincter increase in intestinal contractions; reduces the
- tightens to maintain continence until voluntary perception of pain
defecation can take place,

● relaxation of the internal → relaxation of the external → Acute Inflammation of Intestines

Valsalva's maneuver
● Reflex defecation Appendicitis

- continues to occur even in the presence of
Most upper and lower motor neuron lesions,
because the musculature of the bowel
contains its own nerve centers that respond to
distention through peristalsis.
● defecation even when motor paralysis is present.
● Bowel training
- the major approach used with patients who
have cognitive and neurologic problems
● Biofeedback training
- cornerstone of therapy for patients who have
motility disorders or sphincter damage that
causes fecal incontinence.
● Incontinence
- a major issue in home care and often is cited
as the most common reason for older
persons being admitted to nursing homes.
● High Fiber diet
● At least 2.5 L of fluid daily.
● regular stool softener or bulk former.
● glycerin suppository - after breakfast
Irritable Bowel Syndrome
● most common chronic disorders
● Women
● combination of chronic and recurrent GI symptoms,
○ abdominal pain,
○ Distention,
○ disturbed defecation
● A functional disorder
● Disturbances in nervous system control of the intestines
that cause visceral hypersensitivity and abnormal
bowel motility.
● Due to Serotonin
● One of the most common surgical emergencies.
● result from obstruction of the narrow lumen of the
appendix, most often with a fecalith (hardened feces)
or a foreign body
● Obstruction = increased intraluminal pressure =
capillary and venules occlusion = ischemia = bacterial
invasion
● Males
● low in fiber and high in refined carbohydrates = fecaliths
= appendicitis
● More rapidly developing cases have a risk of rupture
and acute peritonitis.
● primary clinical manifestation
- abdominal pain that comes in waves.
● Pain
- starts in the epigastric or umbilical region
- gradually becomes localized in the right lower
quadrant of the abdomen.
● McBumey’s point -
- halfway between the umbilicus and the
anterior spine of the ileum
● Rebound tenderness
- a common finding
● Fever
● High WBC
● Nausea, vomiting, anorexia
● delay/undiagnose = perforation = abscess
● CT scan - not for children and pregnant
● Ultrasound
● Other symptoms must be ruled out first
● Heat is not applied to the abdomen
- because the increased circulation to the
appendix can lead to rupture.
● Bowel function
- usually returns to normal soon after surgery,

● Manifestations:
○ abdominal pain Diverticular Disease and Diverticulitis
○ Diarrhea and constipation, or an alternating ● Diverticula
pattern of the two - are small outpouchings or herniations of the
○ mucus in the stool mucosal lining of the colon
○ a sensation of incomplete evacuation; ● Left colon and rarely occurs alone.
 ● increase with age ■ Chemical irritation (gastric acid,
● Asymptomatic pancreatic juice, bile)
● Diverticulitis ○ aseptic
- an episode of acute inflammation that can ○ septic,
occur from local obstruction of a ○ Acute
diverticulum by mucus or fecal matter. ○ Chronic.
● Diverticulosis ● end result = abscess
- ( uninflamed diverticula) ● Adhesions at lower abdomen
● Low-fiber diets ● Hypovolemia, electrolyte imbalance. dehydration, and
- increase intraluminal pressure in the bowel finally shock can develop.
● increased intraluminal pressure in the colon and ● Septicemia
decreased muscle strength in the colon wall Classic signs
- Guarding and rigidit
● most often found in the sigmoid colon, lumen is ● symptoms
narrowest and pressure is highest, - less severe in older persons,
● Treatment focuses
● blood supply to the area decreases, and bacteria - fluid resuscitation
proliferate in the obstructed diverticulum. - antibiotic therapy
- Surgery
● diverticular sac ● Peritoneal lavage
- a thin structure composed entirely of mucosal - with warm saline
tissue, which is easily perforated. ● Bed rest; semi fowlers

● Classic sign of diverticulitis

- Crampy lower left quadrant abdominal pain Inflammatory Bowel Disease
accompanied by low-grade fever
● umbrella
● Nausea vomiting, bloating - term used to describe conditions that are
● One of the most common cause of lower GI bleeding characterized by bowel inflammation.
● Crohn's disease and ulcerative colitis
● Meckel’s Diverticulum - the two major forms.
- congenital; leftover of the umbilical cord; most ● genetic - most important risk factor
common congenital defect of the ○ chromosomes 5 and 6
gastrointestinal tract ○ CARD15 gene,
● CT scan ● Smokers = chrons
● Barium enema ● Nonsmoker = ulcerative colitis
- not perform after inflammation subsides ● Causes:
● resting the bowel. ○ Stress
● end-to-end anastomosis ○ Emotional factors
● temporary colostomy ○ Immune system dysfunction
● asymptomatic diverticulosis ■ Environment - trigger
- prevention of constipation is the goal ● inflammation
● 2.5 to 3 L/day - the hallmark of both Crohn's disease and
● soft foods ulcerative colitis,
● high fiber (20 to 35 g of fiber daily.) - NOT when ● Women
inflammation ● 15- 25 y.o
● Bran ● First-degree relative
● Avoid nuts or seeds
● Avoid abdominal pressure
● Loss Weight
Ulcerative Colitis
● Bowel mucosa and creates a diffuse,
Peritonitis ● edema and shallow ulceration
● distal colorectal area,
● peritoneum ● left sided
○ the membranous lining of the abdomen that ● ulcerative proctitis
covers the viscera, - confined to the rectum ; less virulent
○ semipermeable ● Classic symptoms of ulcerative colitis.
○ flow of water and electrolytes between the - Bloody diarrhea and abdominal pain
bloodstream and peritoneal cavity. ● left-sided abdominal pain that is colicky and relieved by
○ Fluid shift to abdominal cavity emptying the bowel.
- 300 to 500 ml/hr in ● Result to losses of fluids, sodium, potassium,
bicarbonate, and calcium.
● Cause:
- bacteria or intestinal contents in the peritoneal
cavity, Crohn’s DISEASE.
● Types: ● any portion of the digestive tract
○ Primary - no cause ● most often in the proximal colon and ileocecal junction,
■ Spontaneous bacterial peritonitis - ● Right-sided
common primary ● “skip” or “cobblestone” pattern
○ secondary, - with cause usually ● lesions may perforate and form fistulas
■ Infection
■ Bacteria ● Classic features of Crohn's disease
 - Diarrhea and abdominal pain ○ Incarcerated hernia
■ Irreducible with bowel obstruction
Systemic AND EXTRAINTESTINAL SYMPTOMS OF ○ Strangulated hernia
INFLAMMAtory bowel disease ■ Blood flow is compromised

Bowel Obstruction
● Types:
Nursing Diagnosis IBS ○ Mechanical (affecting the intestinal lumen)
○ nonmechanical (related to peristalsis)
● Chronic pain ○ Partial
○ Anticholinergic ○ Complete
○ Antispasmodics
○ Heat on abdomen but NOT during acute Mechanical Obstruction
● Diarrhea
○ focus of care during exacerbations of the Adhesions
disease process ● fibrous bands of scar tissue
○ Antidiarrheal agents (loperamide) ● most common cause of small bowel obstruction
- slow peristalsis ● closed loop,
○ mucilloids such as psyllium = bulk ● strangulation
○ limit activity when diarrhea is severe
○ lie down for 20 minutes after meals to limit Volvulus
peristalsis. ● twisting of the bowel on itself,
○ Anal care ● at least 180 degrees
○ 2.5 to 3 L/day)
Hernias
● Imbalanced Nutrition: Less Than Body ● strangulated
Requirements
○ Bowel rest Tumors
- can be helpful in Crohn's disease ● majority of obstructions of the large intestine,
○ Elemental feedings, ● sigmoid colon - mostly
○ low-residue, high-protein, high-calorie diet
○ salt intake INTUSSUSCEPTION
○ Only foods known to cause problems are ● leading segment of bowel invaginates into an adjacent
restricted segment
○ No milk
○ Take Multivitamin and mineral supplements OtHerR Causes
● Ineffective Coping ● fecal impaction
● Ineffective Health Maintenance ● Gallstones
● strictures
● Surgical intervention i
- avoided in older Nonmechanical Obstruction

ILeus
Obstructive Disorders ● impaired or absent peristaltic motility
● Aka adynamic or paralytic ileus
Abdominal Hernias ● absence of peristalsis for longer than 72 hours.
● protrusion of an organ or structure from its normal
cavity OTHER Causes.
● Men
● Older ● multiple sclerosis, Parkinson's disease, or
● Indirect inguinal hernias Hirschsprung’s disease).
○ develop from weakness of the abdominal ● Primary collagen or muscle disorder
wall at the point where the spermatic cord ● DM
emerges. ● Thrombosis of the mesenteric arteries
○ Most common - a possible complication of heart disease in
○ men older adults
● Direct inguinal hernias
○ pass through the posterior inguinal wall at a
point of muscle weakness, ● 7 to 10 L of electrolyte-rich fluid
○ Due to increased intraabdominal pressure - secreted into the small intestine each day.
■ Older men ● 600 to 800 ml
○ Femoral hernias - resorbed before the chyme enters the cecum.
■ Women ● 200 ml
○ Umbilical hernias - lost daily in the stool.
○ incisional hernias ● 2 to 6 L within 2 to 3 days
○ sliding hernia - mechanical bowel obstruction.
■ moves freely in and out of the hernia ● x-ray films
sac. - generally show clear patterns of air and fluid
○ Reducible hernia entrapment in the obstructed area.
■ requires manipulation to return it to its
proper position, Colorectal Cancer
○ Irreducible hernia ● familial adenomatous polyposis.
■ Cannot be returned ○ Autosomal dominant disorder
 ○ Gardner's syndrome ● Colonoscopy
■ Causes osseous and soft tissue - to rule out cancer.
tumors.
■ Many polyps Anal Fissures, Abscesses, and Fistulas
● familial nonpolyposis syndrome, ● from trauma or infection in the anorectal area.
○ Autosomal dominant disorder
○ small number of bowel polyps but malignant ● Anal fissure
○ Painful elongated tear between the anal canal
● Risk: and the perianal skin, most often along the
○ Diet Low in fiber, high in fat posterior midline.
○ Obesity ○ Primary - idiopathic
○ Smoking ○ Secondary - associated with chronic
○ Family constipation
○ ulcerative colitis
● Anal abscesses
● Colorectal cancer ○ from feces obstructing gland ducts in the
- third most commonly occurring cancer and anorectal region, but they also may complicate
the third most common cause of death from the presence of a fissure
cancer in adults of both sexes. ○ Men

● Shape: ● Anal fistula

○ typically round and polypoid (sessile) ○ abnormal communication between the anal
○ elongated and have stalks (pedunculated). canal and skin outside the anus.
○ flat or even depressed
● Pain
● Dukes’ and the universal TNM classifications - primary problem associated with anal fissures
- for staging and abscesses.

● left colon CHAPTER 44 Gallbladder and Exocrine Pancreatic Problems

- narrower than the right
Problems of the Gallbladder
● Colonoscopy
- considered the gold standard for colorectal 1. Cholelithiasis, Cholecystitis, and Choledocholithiasis
cancer diagnosis,
● Surgery ● cholelithiasis
- the treatment of choice for colorectal cancer. ○ refers to stone formation in the gallbladder
● Chronic constipation ○ most common biliary disorder.
- a frequent complaint in older adults ○ Theory of cause
■ imbalance in bile components that
leads to supersaturation and
Anorectal Disorders crystallization

Hemorrhoids ○ Risk factors

● masses of dilated blood vessels that lie beneath the ■ Women
lining of the skin in the anal canal. ■ Obesity
● dilation of the superior and inferior hemorrhoidal veins, ■ Middle age
■ Rapid weight loss
● Causes ■ Pregnancy, multiparity, use of oral
○ Pregnancy contraceptives
- common initiating condition. ■ Hypercholesterolemia, use of anti
○ Obesity cholesterol medications
○ congestive heart failure, and ■ Diseases of the ileum
○ chronic liver disease with portal hypertension
○ persistent elevations in intra abdominal ○ Diet
pressure. ■ Low-carbohydrate
○ Sedentary occupations ■ caffeinated coffee
○ Chronic constipation and diarrheal diseases ○ Exercise
such as IBD
○ Symptomatic gallbladder disease
● Internal hemorrhoids - one of the most common GI
○ occur above the anal sphincter. disorders requiring hospitalization.
○ asymptomatic
● External hemorrhoids ○ There must be balance between the three
○ Below the anal sphincter lipids (bile salts, lecithin, and cholesterol). If
not cholesterol precipitate = gallstones
● varicose veins of the rectum. ○ mucin glycoprotein
● thrombosed external hemorrhoid ■ Enhanced the production of
○ After exercise Cholesterol gallstone formation
○ after a severe episode of diarrhea or ■ which traps cholesterol particles.
constipation
○ Cholesterol stones
● Proctoscopy or sigmoidoscopy - soft, yellowish green, and radiolucent.
- used to confirm the diagnosis,
 ○ The process of stone formation is Slow. 2. Primary Sclerosing Cholangitis

○ Black stones ● sclerosing cholangitis

■ result from an increase in ○ refers to a variety of pathologic processes that
unconjugated bilirubin and calcium cause bile duct injury from inflammation,
with a corresponding decrease in bile fibrosis, thickening, or strictures
salts ● Causes:
■ small, hard, and usually numerous ○ Gallstones
○ infections
○ Biliary colic ● idiopathic or primary sclerosing cholangitis (PSC).
■ is the classic clinical manifestation of ○ No cause
symptomatic gallstones ○ Most important link
■ is with inflammatory bowel disease
○ Symptoms (IBD)
- typically milder and more subtle in ■ ulcerative colitis patients
older adults, ■ Crohn's
● Men
○ When gallstones pass into the common bile ● third most common reason for liver transplant in adults.
duct, they may obstruct the flow of bile and ● does not usually involve the gallbladder or cystic duct.
cause jaundice and pruritus. ● = Elevated liver enzymes and serum bilirubin levels,
■ Cholangitis
- a serious potential ● Elevation in alkaline phosphatase
complication ○ hallmark feature of the disease.
- an inflammation of the bile
duct system ● ERCP
● Liver Biopsy
○ if the stone obstructs the sphincter of Oddi = ● Ursodeoxycholic acid
acute pancreatitis ○ Improve the biochemical abnormalities of
PSC.
○ Ultrasonography
- primary diagnostic tool for ● Liver transplantation
identifying cholelithiasis. ○ the only curative option.

○ Endoscopic retrograde ● cholestyramine resin

cholangiopancreatography (ERCP) ○ binds the itch-triggering elements in the bile.
■ is preferred for identifying and ○ For pruritus
treating stones in the common bile ● Diet
duct. ○ Low-fat
○ Fat Soluble vitamin replacement
○ Surgery
■ treatment of choice for symptomatic 3. Carcinoma of the Biliary System
gallstones.
● Rare
○ Laparoscopic cholecystectomy ● Older
■ standard of care for the treatment of ● Women
gallstones. ● Presence of gallbladder stones
- a significant risk factor for cancer.
○ Oral dissolution therapy with
ursodeoxycholic acid (ursodiol [Actigall]) ● Cholangiocarcinoma
■ may be prescribed for patients who ○ Parasitic infections
are poor surgical risks or who refuse
surgical treatment.’ ● Intermittent pain in the upper abdomen
○ most common symptom.
○ Extracorporeal shock wave lithotripsy
■ uses shock waves to disintegrate ● jaundice
stones - indicates spread beyond the gallbladder.

○ Most common complication of the ● Surgery

nonsurgical management of gallstone ○ primary treatment for cancer of the gallbladder.
disease ● Tx focus
- recurrence, ○ Maintain bile flow; patency

○ symptomatic cholecystitis
■ Diet: Problems of the Pancreas
● low-fat diet
● small meals 1. Acute Pancreatitis

● Cholecystitis, ● syndrome
● choledocholithiasis. ● defining characteristics
○ stones form in or migrate to the common bile ○ abdominal pain
duct, ○ elevated pancreatic enzyme levels,
● Two major causes ● Meds:
○ biliary stones ○ Pain management is the primary
○ alcohol abuse consideration,
● Women ○ Opioids
● Older
● Pancreatitis
● Alcohol-related pancreatitis - often leads to “third spacing,”
○ younger
○ Male ● (NPO) until the abdominal pain
- has subsided and amylase levels have
● Biliary Pancreatitis returned to normal.
○ Causes ○ Hunger
■ transient obstruction of the ampulla of - is a good indicator of readiness for
Vater. eating.
■ presence of tiny gallstones
(microlithiasis or biliary sludge) ● abstinence from alcohol.
■ structural abnormalities = narrowing ● Pain control- major priority
at the sphincter of Oddi ● Infection
○ Two major pathologic varieties - common complication of pancreatitis
■ (1) the acute interstitial form
● Milder 2. Chronic Pancreatitis
● interstitial pancreatitis the
gland is diffusely swollen ● persistent and progressive functional and morphologic
and inflamed but retains its damage to the tissue.
normal anatomic features
● No hemorrhage ● Malnutrition
● No necrosis ○ most common cause of chronic pancreatitis
■ (2) the acute hemorrhagic form.
● gland is acutely inflamed ● basic pathologic change of chronic pancreatitis
● With hemorrhage ○ destruction of the exocrine parenchyma
● With marked tissue necrosis ○ Replacement with fibrous tissue
●
○ Pancreatic secretions normally contain only ● The disease therefore can lead to insufficiency or failure
inactive forms of the proteolytic enzymes. of both the exocrine and endocrine functions of the
The pancreas secretes a trypsin inhibitor gland.
specifically to prevent activation of these
enzymes within the gland, because once ● Abdominal pain
trypsinogen is activated to trypsin, it can then ○ major symptom,
activate the other enzymes as well. Activation ○ Severe, dull, constant
of the pancreatic enzymes before they reach ● Bowel rest
the duodenum has long been recognized as a ● Diet
major component of the disease process. ○ low-fat
○ High protein
○ pancreatic autodigestion ○ High carbohydrates
■ Enzyme activation overwhelms all the ● supplemental pancreatic enzymes,
normal protective mechanisms of the ● Fat-soluble vitamin replacement
pancreas and initiates a massive ● Insulin
attack on the pancreatic tissues,
○ Acute pain in the epigastric region 3. Cancer of the Pancreas
■ the hallmark of the disease
● malignant disease of the exocrine pancreas
● Pseudocysts, ● Men
○ localized collections of fluid enclosed in a ● cigarette smoking
fibrous capsule - believed to be an important causative agent.
○ Inflammatory exudate from the pancreas may ● Diet
form into an inflamed mass, which is called a ○ Fresh fruits and vegetables
phlegmon ○ Aspirin
● Most common symptoms
● Pancreatic infection ○ Pain
○ most frequent cause of serious morbidity and ○ jaundice
mortality associated with acute pancreatitis ■ produced from compression and
obstruction of the bile duct.
● Chronic Pancreatitis ● = light colored stools and
○ alcohol-induced acute pancreatitis dark, frothy urine.

● Diagnosis ● Surgical resection

○ acute abdominal pain ○ only curative option available for pancreatic
○ elevated serum amylase level, cancer

○ Ultrasonography ● Delayed gastric emptying and pancreatic leaks or

■ best noninvasive method for fistulas
identifying gallstones and can reveal - Most common complications associated with
pancreatic edema the surgery.
 ● Collateral circulation
CHAPTER 46 Hepatic Problems ○ = massive GI bleeding
■ Surgical creation of shunt
● The most dreaded outcome of any liver disorder is
liver failure.
○ Ascites
I. Liver Failure ■ is the accumulation of fluid in the peritoneal
cavity, resulting from changes in the
A. Acute Liver Failure hemodynamics of the abdominal circulation.
● Aka fulminant hepatic failure ■ Causes respiratory distress
● previously healthy persons develop severe liver ■ Restriction of sodium and diuretic therapy
dysfunction evidenced by the rapid onset of ■ paracentesis or shunting
encephalopathy and/or bleeding. …….1321 - 1324
● Causes:
○ Hepatitis B infection ○ Portal-systemic encephalopathy (PSE)
○ major cause of ALF in persons without ■ Aka hepatic encephalopathy or hepatic coma,
another liver disease ■ Major cause Is the liver's inability to
- acetaminophen overdose. metabolize and cleanse the blood of ammonia
and mercaptans,
○ Less common causes ■ Ammonia
- poisoning with mushrooms ● end product of protein metabolism,
(Amanita muscaria) ■ mercaptans
- eclampsia or preeclampsia of ● are toxins produced from the metabolism
pregnancy. of sulfur-containing compounds.
● lactic acidosis
● circulatory failure ○ hepatorenal syndrome.
● High Ammonia levels ■ sudden kidney failure for no known
● Cerebral edema cause
● Severe bleeding disorders ■ has oliguria and azotemia.
○ DIC ■ onset of hepatorenal syndrome is a
● Severe infections grave sign in a patient with liver
● Septicemia failure.
● Prolonged prothrombin time
● Jaundice ● Meds
○ antihistamines
● primary treatment for ALF is organ transplantation. ■ For pruritus from jaundice;
○ potassium supplements
■ Correct hypokalemia;
B. Chronic Liver Failure ○ diuretics (particularly aldosterone antagonists
■ For edema, hyperaldosteronism
● Aka end-stage liver disease ○ Sodium and fluids are also usually restricted
○ Albumin

II. Diffuse Hepatocellular Disorders

B. Hepatitis
● those which spread through a major portion of the liver ● any acute inflammatory disease of the liver.
● Focal ● = postnecrotic cirrhosis if not treated
○ Localizes to one portion of the liver
1. Toxic Hepatitis
A. Cirrhosis of the Liver ● predictable(intrinsic) hepatotoxins
● chronic disease of the liver \ ■ acetaminophen
- characterized by diffuse inflammation and ○ Direct
fibrosis resulting in drastic structural ○ Indirect
changes and significant loss of liver function, ● nonpredictable (idiosyncratic) hepatotoxins.
○ Most drugs
● Alcoholism and malnutrition
○ are two major predisposing factors for ● A major cause of toxic hepatitis is the use
cirrhosis. of acetaminophen,

● Laénnec’s cirrhosis ● Gastric lavage and cleansing of the bowel

○ fatty infiltration of the liver is the first alteration ○ may be indicated to remove the
seen. hepatotoxin from the intestinal tract.

● Primary biliary cirrhosis 2. Autoimmune Hepatitis

○ Autoimmune
● chronic necroinflammatory liver disorder
● Complications ● circulating autoantibodies
○ Portal hypertension, ● high serum globulin levels.
● Varices
○ Collateral vessels in the ● Any age
upper stomach and ● Women (15-40
esophagus
 ● responds well to corticosteroid therapy
● Corticosteroids are the mainstay
○ azathioprine (Invuran}

3. Viral Hepatitis
● most important liver infection
● HAV and HBV - most common

● Young adults

● Chronic hepatitis C
- most common chronic liver disease

● Jaundice
- a common clinical manifestation of
hepatitis, is caused by a disturbance
in bilirubin metabolism.
○ Dark urine
○ pruritus

● Clay-colored (grayish white) stools

- indicate that bile is not reaching the
intestines and suggest extrahepatic
obstruction.

● ALT and AST

- present in hepatitis A and B.

● Vitamin K
- may be necessary if the prothrombin
time is prolonged.

● Chronic hepatitis C
- are treated with interferon,

● Diet
- low-fat, high-carbohydrate diet

● Protein and sodium

- restricted if liver function is
compromised.

● Abstinence from alcohol