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Doubtfireyou
look pale
Problem
While you were watching Harry Potter and The Goblet of Fire in
TV at the emergency department you worked for as a doctor,
suddenly came a woman, who looks pale, held by her husband. At
the doorway, shes vomiting blood with a coffee ground appearance.
Its known that the patient is Mrs. Doubtfire, a 55-years old
woman. Tonight, at home, she had a sudden episode of
hematemesis. She also feels dizzy. She describes abdominal
discomfort in the epigastric area that started 3 days prior to
presentation. But actually, she has felt that symptom comes and
goes for about the past 6 months. Usually, it can be relieved either
by eating food, or by taking the over the counter antacid.
Yesterday, she had 2 bowel movements that were dark, sticky and
foul-smelling. She woke up nauseated and has since twice vomited a
small amount of bright red blood.
On physical exam, you find an alert patient. Her blood pressure is
90/60 mmHg, and her pulse is 110 beats/minute. Her abdomen is flat
with hypoactive bowel sounds. She denies using aspirin or NSAIDs.
Learning Objective
To learn and know about :
Anathomy of gastrointestinal system
Physiology of gastrointestinal system
Mechanism of vomit
Differential between UGIB and LGIB
Diseases of UGIB
Dyspepsia
Dyspepsia
Ascertaining the location of the pain
(upper or lower, localized or diffuse),
its character (sharp, burning,
cramping), and its relationship to
meals will often provide clues into the
most important diagnostic
considerations.
Gastrointestinal Bleeding
Hematemesis is the vomiting of blood,
which may be obviously red or have an
appearance similar to coffee grounds.
Occasionally hemoptysis or vomiting of
swallowed blood from epistaxis can be
confused with hematemesis
Melena is the passage of black, tarry
stools.
Hematochezia is the passage of fresh
blood per anus, usually in or with stools.
Bleeding diagnosed
X-rays or other imaging tests (abdominalCTscan,
abdominalMRI)
Endoscopy
Capsule endoscopy
Other procedures
Angiography
is a technique that uses dye to highlight blood
vessels allows the dye to leak out of the blood
vessel, which identifies the site of bleeding.
Radionuclide scanning
is a non-invasive screening technique used for
locating sites of acute bleeding, especially in the
lower GI tract.
Abdominal/bowel sound
Abdominal sounds (bowel sounds) are
made by the movement of the intestines as
they push food through.
Bowel sounds can echo throughout the
abdomen much like the sounds heard from
water-pipes.
The majority of bowel sounds are harmless
and simply indicate that the
gastrointestinal tract is working.
A doctor can evaluate abdominal sounds by
listening to the abdomen with a
stethoscope.
Abdominal/bowel sound
Reduced (hypoactive) bowel sounds include a
reduction in the loudness, tone, or regularity of
the sounds. They indicate a slowing of
intestinal activity.
Hypoactive bowel sounds are normal during sleep,
for a short time after the use of certain
medications and after abdominal surgery.
Decreased or absent bowel sounds often indicate
constipation.
Hyperactive bowel sounds reflect an increase
in intestinal activity. This can sometimes occur
with diarrhea and after eating.
Vomiting
Vomiting is abnormal emptying of stomach and
upper part of intestine via esophagus through
mouth.
Causes:
1. Irritation in GIT
2. Mechanical stimulation of pharynx
3. Pregnancy
4. Alcohol
5. Stimulation of labyrinth of ear eg sea sickeness,
mountain sickeness
6. Acute GI infection
7. Metabolic disorders
8.Increase Intracranial Pressure
Emesis mechanism
Emesis mechanism
Anatomy and Physiology
Physiology - Digestive
System
The functions of the digestive system are:
Ingestion - eating food
Digestion - breakdown of the food
Absorption - extraction of nutrients
from the food
Defecation - removal of waste products
The digestive system is a group of organs
that breakdown the chemical components
of food, with digestive juices, into
micromolecul nutrients which can be
absorbed to generate energy for the body
The bucal cavity (mouth) and
salivary glands
Food enters the mouth and is chewed by the
teeth, turned over and mixed with saliva by
the tongue.
Mouth: the salivary glands. Saliva produced
by these glands contains an enzyme that
begins to digest the starch from food into
smaller molecules. ptyalin enzyme
The Stomach
It is the widest part of the alimentary canal
and acts as a reservoir for the food where it
may remain for between 2 and 6 hours.
Here the food is churned over and mixed
with various hormones, enzymes including
pepsinogen which begins the digestion of
protein, hydrochloric acid, and other
chemicals
The stomach has an average capacity of 1
liter, varies in shape, and is capable of
considerable distension.
At regular intervals a circular muscle at the
lower end of the stomach, the pylorus opens
allowing small amounts of food, now known
as chyme to enter the small intestine.
Duodenum
Small Intestine
The small intestine measures about 7m in an
average adult and consists of the duodenum,
jejunum, and ileum.
Both the bile and pancreatic ducts open into
the duodenum together.
The small intestine, because of its structure,
provides a vast lining through which further
absorption takes place.
The Large Intestine
The large intestine averages about 1.5m
long and comprises the caecum, appendix,
colon, and rectum.
Here most of the water and electrolytes is
absorbed, much of which was not ingested,
but secreted by digestive glands further up
the digestive tract.
The colon is divided into the ascending,
transverse and descending colons, before
reaching the anal canal where the
indigestible foods are expelled from the
body.
Chase
Table 282-1. Overview of Approach to Patients with Common Gastrointestinal Disorders
SmallIntestine
PATHOPHYSIOLOGY H. pylori
PATHOPHYSIOLOGY
NSAIDs
PATHOPHYSIOLOGY
NSAIDs
CLINICAL FEATURES
Epigastric pain can be present in both DU and GU.
Pain pattern in DU occurs 90 min to 3 h after a
meal and is frequently relieved by antacids or
food.
Pain that awakes the patient from sleep (between
midnight and 3 A.M.) is the most discriminating
symptom, with two-thirds of DU patients
describing this complaint.
GU discomfort may actually be precipitated by
food.
Nausea and weight loss occur more commonly in
GU patients.
Hematemesis
CLINICAL FEATURES
Other symptoms are :
losing weight
not feeling like eating
having pain while eating
feeling sick to your stomach
vomiting
Related Complications
Gastrointestinal Bleeding
Perforation
Gastric Outlet Obstruction
Treatment
GASTRIC ADENOCARCINOMA
Epidemiology
Gastric cancer incidence has decreased
worldwide but remains high in Japan, China,
Chile, and Ireland.
The risk of gastric cancer is greater among
lower socioeconomic classes.
Etiology
PATHOPHYSIOLOGY
Gastric carcinomas spread by direct
extension through the gastric wall to the
perigastric tissues, occasionally adhering to
adjacent organs such as the pancreas,
colon, or liver.
The disease also spreads via lymphatics or
by seeding of peritoneal surfaces.
The liver is the most common site for
hematogenous spread of tumor.
Clinical Features
upper abdominal discomfort
Anorexia
slight nausea and vomiting
Weight loss
Dysphagia (caused by lesions of the
cardia)
iron-deficiency anemia
occult blood in the stool
TREATMENT
Gastrectomy
subtotal gastrectomy is the treatment
of choice for patients with distal
carcinomas, total or near-total
gastrectomies are required for more
proximal tumors.
chemotherapy combined with
radiation therapy has been shown to
reduce the recurrence rate and
prolong survival
Conclusion
Mrs. Doubtfire probably having UGIB
disease based on the symptoms that
she had
The diseases of UGIB are:
Varices Esophagus
Gastritis
Peptic Ulcers (DU and GU)
Adenocarsinoma Gaster
Suggestion
Mrs. Doubtfire needs to have an
endoscopy to make sure what illness
that she has
Take a meal in a small portion, but
frequently
Give education to patients and other
people
Summary
1. Contran, Kumar, Collins. Robbins Pathologic Basis of
Disease. 6th edition. Saunders company
2. Rubin, Ravael. Rubins Phatology clinicopathologic
foundation of Medicine. 5th edition. Philadelphia
3. Buku Ajar Ilmu Penyakit Dalam, edisi 3, jil. 1, Balai Penerbit
FKUI: Jakarta, 2001.
4. Litien,scott C. Mayo Clinic Family Heath Book. 5th edition.
2009. Jakarta : Gramedia.
5. http://digestive.niddk.nih.gov/ddiseases/pubs/cvs/index.ht
m
6. http://www.nlm.nih.gov/medlineplus/ency/article/003118.h
tm
7. http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=
1411788&blobtype=pdf