Lesson 1

GI pathology
 GI disorder symptoms
• Anorexia, nausea, and vomiting are all
physiological responses that are a common to
many gastrointestinal disorders
• Anorexia represents a loss of appetite
• Vomiting, or emesis is the sudden and forceful
oral expulsion of the contents of the stomach
• Hematemesis refers to blood in the vomitus;
may be bright red or have a “coffee-ground”
appearance because of the digestive enzymes
 Digestive system anatomy
Really this is one long
continuous tube with
openings on either end:
• Mouth
• Pharynx
• Esophagus
• Stomach
• Small intestine
• Large intestine
(bowel/colon)
• Rectum
 Small intestine
• Proximal: duodenum

• Middle: jejunum

• Distal: ileum
 Large intestine
• Proximal: caecum and
appendix
• Middle: ascending,
transverse and
descending colon
• Distal: sigmoid colon
and rectum
 Esophagus

– Passageway for food

– Contains 4 layers: mucosa,

sub-mucosa, muscle layer,
and adventitia

– The mucosa contains

glands which secrete
mucus for lubrication of
food
 Esophagus

The muscles of esophagus:

upper 1/3 – skeletal muscle,
middle 1/3 – both skeletal
and smooth muscle,
lower 1/3 – smooth muscle

– The sphincter between

esophagus and stomach is
known as the cardiac
sphincter or Gastro-
Esophageal Sphincter (GES)
 What is a sphincter?
• It is a circular shaped
muscle that is an
attachment point from
one structure to the
next
• It allows for the passage
or blockage of material
to enter the next
structure
 Esophagitis

– Inflammation of esophagus

– The most common etiology

is Gastro Esophageal Reflux
Disease (GERD) because
the sphincter is weak
– The acid and pepsin reflux
upward and damage the
esophageal layer
 GERD

– Manifestations: heartburn which may mimic

angina pectoris (chest pain due to myocardial
ischemia or infarction)
 Esophagitis timeline
• Acute esophagitis cause inflammation and
manifests as heartburn

• Latent esophagitis is usually due to ulcers in

the esophagus causing chronic bleeding and
blood loss

• Chronic esophagitis can cause scarring in

esophagus  stenosis & obstruction
 Esophageal obstruction

– Can be due to organic causes

like esophageal tumor or
compression effect by
adjacent organ or cervical
diseases

– The most common type is

achalasia in which there is
paralysis of the esophageal
muscle and spasm of GES

– The main complaint is

difficulty in swallowing
(dysphagia)
 Stomach
• Contains gastric glands
which secrete mucus,
acid, enzymes

• Digestion of food both

by mechanical means
and enzymes occurs in
the stomach
 Gastritis

– Inflammation of the
stomach can be acute or
chronic causes
– Acute gastritis is cause by
irritant foods, corrosives,
alcohol, or high level of
stress

– Acute gastritis is
manifested by pain,
dyspepsia, vomiting and
bleeding
 Chronic Gastritis

– Chronic gastritis is
usually caused by a
bacteria called
Helicobacter Pylori
– Chronic inflammation of
stomach can cause
atrophy of gastric glands
– Reduced food digestion
and dyspepsia
 Peptic Ulcer

– ulceration (eating away) of

the internal layer of
stomach, duodenum or
lower part of esophagus
– Peptic ulcers can be in the
stomach and/or small
intestine

– Duodenal ulcers and

gastric ulcers are the 2
most common types of
peptic ulcers
 Gastric Ulcer
• pain starts immediately
after eating a meal due to
acid secretion on the ulcer

– Pathogenesis: risk
factors like stress,
smoking, and alcohol can
alter the mucus
secretion of the stomach
 Gastric Ulcer

– Complications include:
perforation,
hemorrhage, obstruction
(due to scar formation)
and tendency to convert
gastric cancer.
– Gastric ulcers are in the
stomach only
 Duodenal Ulcer
– more common
– Main
manifestation is
pain when
stomach is empty.
usually begins in
1-2 hours after
meal, and the
pain is relieved
immediately after
eating a meal
 • Longitudinal tears
in the esophagus at
the
esophagogastric
junction
• Most often in
chronic alcoholics
after a bout of
severe retching or
vomiting
• May also occur
during acute
illness with
severe vomiting
Tears (Mallory-Weiss
Syndrome)
 Appendicitis

– Poor bowel habits and

inadequate dietary fiber
may lead to obstruction
of lumen of appendix
• Sharp pain in right lower
quadrant
• generalized tenderness in
abdominal wall
• aggravated by
movements, nausea /
vomiting and low grade
fever
 Appendicitis
• Acute appendicitis is extremely common; seen
most frequently in the 5-30 year age group
• Appendix becomes inflamed, swollen, and
gangrenous; eventually perforates if not
treated
• Usually has an abrupt onset with pain referred
to the epigastric or periumbilical area
 Appendicitis
• Rebound tenderness,
which is pain that
occurs when pressure is
applied to the area and
then released, and
spasm of the overlying
abdominal muscles are
common
 Colonic Polyps

– A polyp is typically an overgrowth of normal

tissue, arising from a mucosal surface and
extending into the lumen
– Most polyps in large intestine are symptom free,
but there are chances of conversion to malignancy
 Colonic Polyps
There are two types of
polyps:
1) Pedunculated- attached
to the wall by a stalk.
• It is more common with
increasing age and most
often found in sigmoid
colon
• the chance of malignancy
is minimal but increases
with increasing size of
polyps
 Colonic Polyps
2) Sessile-broad base polyp

• Usually occurs in sigmoid

colon or rectum
• risks of malignancy are
higher than pedunculated
polyp
 Familial Polyposis

– Rare genetically
transmitted disorder of
large intestine

– There are multiple

polyps, and the risk of
cancer increase with age
 Diverticular Disease

– A diverticulum is a balloon like pouch which forms

at intervals in large intestine
– When a lot of diverticula are present in the
intestines the condition is called diverticulosis
 Diverticulosis

– It can cause chronic

constipation which can
cause compression of
blood vessels and
ischemia, necrosis
– Etiology: Exact cause
unknown. May be due to
low fiber diet and poor
bowel habits
 Diverticulitis
• If a diverticulum becomes
inflamed, it is called
diverticulitis
• Most common cause is E.
Coli

• Diverticulosis is the
presence of these knobs
and diverticulitis is
when they become
inflamed
 Irritable Bowel Syndrome

– functional disorder of GI tract

– Etiology: psychological stress,

foods, lactose intolerance

– Manifestations: alternating
diarrhea and constipation,
abdominal pain, gaseous
discomfort, absence of any
detectable organic disease
– Associated with fibromyalgia
 Inflammatory Bowel Disease
• There are two types of
IBD:
– Crohn’s disease (CD) and
Ulcerative colitis (UC)

– In both diseases there is

inflammation in the
layers of GI tract
 Cobblestone mucosa
• Found in both Crohn’s
and UC
• The mucosa lining of
the intestines should be
smooth, but instead has
bumps like
cobblestones on a road
 Skip lesions
• In Crohn’s, the
cobblestone mucosa is
patchy or intermittent,
hence it is called a “skip
lesion”
• In UC, the cobblestones
are continuous, thus no
skip lesions
 Chron’s symptoms
• watery diarrhea
• abdominal pain
• chronic low grade
fever
• anorexia
• weight loss (due to
malabsorption)
 UC Symptoms
• Bloody/diarrhea
mix because UC
involves and
damages vessels of
the colon
• abdominal pain
• weight loss
 Complications
• scar formation and
stricture of ileum
• fistula formation
(abnormal connection
between ileum and
other organs)
• pernicious anemia (due
to malabsorption of
Vit.B12 in ileum)
• Cancer, but not Chron’s
 Chron’s Vs. UC
Chron’s UC
Location Anywhere, but most Large intestine only
common in ileum of small
intestine
Malignancy Never cancer (benign) Good chance of becoming
cancer (malignant)
Inflammatory pattern skip pattern (some areas continuous (without skip
have inflammation, while lesions)
the area in between is
normal).
 Obesity
• Obesity is defined as a
condition characterized
by excess body fat
• Overweight and obesity
have become national
health problems
– Increase the risk for
hypertension,
hyperlipidemia, type 2
diabetes, coronary heart
disease, and other health
problems
 Obesity
• Excess body fat of obesity significantly
impairs health

– Obesity is the second leading cause of

preventable death in the United States

• Excess body fat is generated when the calories

consumed exceed those expended through
exercise and activity
 Types of body fat
• There are two types of obesity based on the
distribution of body fat:

1)Upper body obesity (also known as central,

abdominal, or male)

2)Lower body obesity is known as peripheral,

gluteal-femoral, or female obesity
 Upper & Lower body obesity
• Research suggests that fat distribution may be a
more important factor for morbidity and mortality
than overweight or obesity
– The presence of excess fat in the abdomen
out of proportion to total body fat is an
independent predictor of risk factors and
mortality
– Waist circumference of 35 inches or greater
in women and 40 inches or greater in men
has been associated with increased health
risk
 • Increasing weight
gain, alcohol, and
low levels of
activity are
associated with
upper body obesity
• These changes
place persons
with upper
body obesity at
greater risk for
ischemic heart
disease, stroke,
and death
independent of
Upper & Lower body total body fat

obesity
 Childhood Obesity
• Obesity is the most
prevalent nutritional
disorder affecting the
pediatric population in the
US
• Major concern of childhood
obesity is that obese
children will grow up to
become obese adults
– Pediatricians beginning to see
hypertension, dyslipidemia,
and type II diabetes in obese
children and adolescents
 Childhood obesity
• Growing concern that childhood and
adolescent obesity may be associated with
negative psychosocial consequences such as
low self esteem and discrimination by adults
and peers
• Childhood obesity is determined by a
combination of hereditary and environmental
factors
– It is associated with obese parents, higher
socioeconomic status, increased parental
education, small family size, and sedentary
lifestyle
 Diarrhea
• The usual definition of diarrhea is the
excessively frequent passage of stools
– Can be acute or chronic; considered to be chronic
when symptoms persist for 3 weeks in children or
adults and 4 weeks in infants
• The complaint of diarrhea is a general one and
may be related to a number of pathologic and
non-pathologic factors
 Constipation
• Can be defined as the infrequent passage of stools; the
problem increases with age

• Some common causes of constipation include:

failure to respond to the urge to defecate,
inadequate fibre or fluid intake, weakness of
the abdominal muscles, inactivity and bed rest,
pregnancy, hemorrhoids
 Constipation
• Diseases associated with chronic constipation
include neurologic diseases (e.g. spinal cord
injury, Parkinson’s, Multiple Sclerosis),
endocrine disorders (e.g. hypothyroidism), and
obstructive lesions in the gastrointestinal tract
• Constipation, in the context of a change in
bowel habits, may be a sign of colorectal cancer
 Intestinal Malabsorption
• Malabsorption is the failure to transport
dietary constituents, such as fats,
carbohydrates, proteins, vitamins, and
minerals, from the lumen of the intestine to
the extracellular fluid compartment for
transport to the various parts of the body
 Malabsorption Syndrome
• Usually have symptoms directly referable to
the gastrointestinal tract that include
diarrhea, steatorrhea, flatulence, bloating,
abdominal pain, and cramps

– Weakness, muscle wasting, weight loss, and

abdominal distention often are present
– Weight loss often occurs despite normal or
excessive caloric intake
 Celiac Disease
• Celiac disease, also known as
celiac sprue and gluten-sensitive
enteropathy, is an immune-
mediated disorder triggered by
ingestion of gluten-containing
grains (wheat, barely and rye)
• Results from an inappropriate T-
cell mediated immune response
against gluten protein in
genetically predisposed people
 Celiac Disease
• The classic form of
celiac disease presents
in infancy and manifests
as a failure to thrive,
diarrhea, abdominal
distention, and
occasionally, severe
malnutrition
 Colorectal cancer
• The cause of cancer of
the colon and rectum is
largely unknown
– Incidence increases with
age and among people
with: a familial history of
cancer, Crohn disease or
ulcerative colitis, or
familial adenomatous
polyposis of the colon
 Colorectal cancer
• Diet is also thought to play a role

– Attention has been focused on dietary fat intake, refined

sugar intake, fibre intake, and the adequacy of such
protective micronutrients as Vitamin A, C and E in the diet
– Hypothesized that high level of fat in the diet increases the
synthesis of bile acids in the liver, which may be converted to
potential carcinogens by bacterial flora in the colon
 Colorectal cancer
• Usually, cancer of the colon and rectum is present
for a long time before it produces symptoms

– Bleeding is a highly significant early symptom, and

it usually is the one that causes persons to seek
medical care
• Prognosis for persons with colorectal cancer
depends largely on the extent of bowel
involvement and on the presence of
metastasis at the time of diagnosis
 Self Test Questions
1) What bacteria most commonly causes gastritis?
2) What part of the bowel is affected by ulcerative colitis
3) Which can become malignant: UC or Chron’s?
4) Which polyps are more likely to become cancerous: pedunculated
or sessile?
5) Which type of ulcer is more common: gastric or duodenal?
6) Where is skeletal muscle found in the esophagus?
7) What can GERD mimic?
8) Where is the pain of appendicitis felt?
9) Which type of ulcer is aggravated after eating a meal?
10) What condition is irritable bowel syndrome associated with most
often?