intestinal diseases

7/24/2019 Intestinal Diseases

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Professor T.A. Dronova

Lecture

SMALL & LARGE

INTESTINE DISEASES

KURSK STATEKURSK STATE

MEDICAL UNIVERSITYMEDICAL UNIVERSITY

Propaedeutics of Internal DiseasesPropaedeutics of Internal Diseases

DDepartentepartent


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SMALL!INTESTINAL DISEASES

SYMPT"MS

Small-bowel !sease "

ma#or cl!n!cal man!festat!ons$

Mot!l!t% !sturbances

Abom!nal a!n & !stent!on

Gastro!ntest!nal blee!n'

Malabsort!on


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SYMPT"MS

Small-bowel !sease suos!t!on$

(e!')t loss

Nutr!t!onal ef!c!enc!es

Abom!nal a!nD!arr)ea !nclu!n' steatorr)ea


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SYMPT"MS

Altere !ntest!nal er!stals!s"

common man!festat!on

Decrease mot!l!t%$aral%t!c !leus *metabol!c !sturbances+

er!ton!t!s,

!ntest!nal obstruct!on w!t) col!c% a!n*tumors+ a)es!ons+ !ntussuscet!ons,

stas!s *erm!tt!n' bacter!al over'rowt),


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SYMPT"MS

D!arr)eafreuentl% accoman!es

small bowel !sease result!n' from

!rect mucosal !nvolvement b%

!nflammator% or !nf!ltrat!ve les!ons

*srue+ re'!onal enter!t!s,

Assoc!ate malabsort!onof fat &

b!le salts - !mortant factor !n t)e

at)o'enes!s of !arr)ea


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DIARR#"EA

Stool we!')t !ncrease / 011 ' er a%accoman!e b% !ncrease stoolfreuenc%

T%es$2smot!c !arr)ea

Secretor% !arr)ea Inflammator% !arr)eaAbom!nal mot!l!t% !arr)ea

Ant!b!ot!c-assoc!ate !arr)ea


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"sotic diarr$ea

Lar'e uant!t!es of non absorbe )%erton!csubstances !n 'ut lumen resent "

flu! enters bowel ue to osmot!c ressure$

Pur'at!ve !ntae General!3e malabsort!on

Sec!f!c malabsort!on *!sacc)ar!aseef!c!enc%,

2smot!c !arr)ea stos w)en at!ent stos

eat!n' of malabsort!ve substances


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Secretor% diarr$ea

Act!ve !ntest!nal secret!on of flu! &electrol%tes w!t) ecrease absort!on$

Enteroto4!n *c)olera+ E.col!,

5!le salts !n colon follow!n' !lealresect!on

6att% ac!s !n colon follow!n' !leal

resect!on6oo oes not affect !arr)ea - cont!nues

ur!n' fast!n'


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Inflaator% diarr$ea

Dama'e to !ntest!nal mucosal cells -

loss of flu! & bloo$

D%senter% *S)!'ella,7lcerat!ve col!t!s


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Anti&iotic!associated diarr$ea!

Pseudoe&ranous colitisAfter ta!n' ant!b!ot!cs *art!cularl%

am!c!ll!n+ l!ncom%c!n & ce)alosor!n -

rouce seuomembranous col!t!s,S!'mo!osco% - mult!le %ellow laues

& !nflammat!on


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SYMPT"MS

Imortant s!'n of small-bowel !sease -

fat malabsort!on

E4tens!ve mucosal ama'e or

l%m)at!c obstruct!on - malabsort!on

s%nrome or rote!n-los!n'

enteroat)%


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MALA'S"RPTI"N

Malabsort!on - !naeuate transort of one

or more of const!tuents of normal !et from

!ntest!nal lumen across !ntest!nal e!t)el!um

!nto ortal c!rculat!on 8LINI8AL 6EAT7RES$

D!arr)ea

Abom!nal a!n D!stens!on

(e!')t loss

Nutr!t!onal ef!c!enc!es


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Nutrient a&sorption

Sites

Duoenum$iron, calcium, magnesium,

folic acid, water soluble vitamins, amino

acids, monosaccharides

9e#unum$fatty acids, amino acids,

monosaccharides, water soluble vitamins

Ileum$ monosaccharides, fatty acids,

amino acids, fat soluble vitamins (A, D, E,

K), vitamin B12 con!ugated bile salts


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Nutrient a&sorption

P$%siolo(% ! ) p$asesLum!nal )ase$ )%rol%s!s &

solub!l!3at!on of nutr!ents

Mucosal )ase$ furt)er breaown ofnutr!ents & transfer !nto cell

Transort )ase$ removal of nutr!ents

!nto vascular or l%m)at!c c!rculat!on


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Intraluinal ala&sorptionDisoders

Pancreat!c !nsuff!c!enc%$

8)ron!c ancreat!t!s

8%st!c f!bros!s *autosomal !sease,

8arc!noma of ancreas

Def!c!enc% of b!le ac!s$

Entero)eat!c c!rculat!on !nterrut!on *resect!on orterm!nal !leum !sease,

Small !ntest!ne colon!3at!on w!t) bacter!a w)!c)econu'ate b!le ac!s *sta'nant loo s%nrome,

7ncoor!nate 'astr!c emt%!n'$

Gastroenterostom%

Part!al 'astrectom%


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Mucosal p$ase ala&sorptionDisoders

General!3e mucosal abnormal!t!es*)!stolo'!call%

abnormal mucosa,$

8oel!ac !sease *'luten-sens!t!ve enteroat)%,

Tuberculos!s Tro!cal srue

L%m)oma

Ra!at!on enter!t!s

()!le:s !sease *macro)a'es !nf!ltrat!on, Malabsort!on of sec!f!c substances*)!stolo'!call%

normal mucosa,$

Lactase ef!c!enc%


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Transport p$ase ala&sorption

Disoders;ascular$ vascul!t!s+ at)eroscleros!s

L%m)at!c$ l%m)an'!ectas!a+

!nf!ltrat!ons


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Mala&sorption S%ndroe

S%ptosGIT s%stem

Gen!tour!nar% s%stem


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MALA'S"RPTI"N

Nutr!t!onalef!c!enc!es

6eatures

6ats Steatorr)ea+ frot)%stools+ water% !arr)ea+we!')t loss

8arbo)%rates 6latulent %ses!a*borbor%'mus,+

abom!nal !stens!on+flatus+ water% !arr)ea


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MALA'S"RPTI"N


6eatures

Prote!n (e!')t loss+ muscle wast!n'+

)%oalbum!nur!a+ oeema+leucon%c)!a

6ol!c ac! Macroc%t!c+

me'aloblast!c anem!a+'loss!t!s+ oral mucosaulcerat!on !n fol!c ac!

ef!c!enc%


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MALA'S"RPTI"N


6eatures

;!tam!n 5=> Macroc%t!c+ me'aloblast!canem!a+ 'loss!t!s+ mental& neurolo'!cal!sturbances

;!tam!n 5comle4

8)e!los!s+ an'ularstomat!t!s+ ermat!t!s+ol%neur!t!s


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MALA'S"RPTI"N


6eatures

;!tam!n 8 5lee!n' tenenc%

;!tam!n A 6oll!cular)%ereratos!s+4erot)alm!a+ n!')tbl!nness


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MALA'S"RPTI"N


6eatures

;!tam!n D &

8alc!um

2steomalac!a*r!cets,+ ro4!malm%oat)%+araestes!a+ tetan%

;!tam!n ? Purura+)emorr)a'es*bru!s!n' & blee!n',


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MALA'S"RPTI"N


6eatures

Iron


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MALA'S"RPTI"N


6eatures

Potass!um 6lacc!!t%+arr)%t)m!as

Ma'nes!um Muscular weaness+

araestes!a+ tetan%(ater Nocturnal !ures!s


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MALA'S"RPTI"N


6eatures

@!nc Poor taste+ ermat!t!s+oor woun )eal!n'

5!le salts (ater% !arr)ea


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SYMPT"MS

Abom!nal a!nue to small !ntest!nal

!sease - usuall% reumb!l!cal or

suraumb!l!cal & often oorl% local!3e

Interm!ttent or col!c% a!n - !n

obstruct!on


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SYMPT"MS

;!sceral a!n" distention or stretching ofintestinal wall or inflammation of overlying #arietal#eritoneum

$olic%y #ain becomes less a##arent rogressively dilated intestine with loss ofmuscular tone

'teady, aching #ain, usually located directly over

inflamed area " acute inflammation of smallintestine with involvement of visceral or #arietal#eritoneum (maybe accom#anied by guarding rebound tenderness " if the #arietal #eritoneuminvolved)


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INTESTINAL DISEASES

SYMPT"MS

Gastro!ntest!nal blee!n' ue to small-bowel

!sease ma% be etecte as occult blee!n'+

or less commonl%+ br!s )emorr)a'e

Aearance of bloo !n stool eens notonl% on blee!n' s!te but also on

)emorr)a'e rate & ra!!t% of trans!t

Small !ntest!nalblee!n' 5lee!n' from colon

5lac or tarr% stool*melena,

Re bloo or clots


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LAR*E!INTESTINAL DISEASES

SYMPT"MS

Ma#or s%mtoms - alterat!on !n bowel )ab!t+rectal blee!n' & a!n

Alterat!on !n bowel )ab!t - a c)an'e from

rev!ous atterns of efecat!on$ diarrhea " #assage of watery or loose stool usually

with increased freuency

consti#ation " infreuent #assage of hard, dry stool

obsti#ation " absence of s#ontaneous bowelmovements

Pers!stent c)an'e !n bowel )ab!ts - !mortantearl% s%mtom of or'an!c colon !sease


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Difference &et+een sall &o+el, lar(e &o+el diarr$ea6eatures Small bowel

!arr)eaLar'e bowel!arr)ea

Stoolvolume

Lar'e Small

Stool colour L!')t Dar


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Difference &et+een sall &o+el, lar(e &o+el diarr$ea6eatures Small bowel

!arr)eaLar'e bowel!arr)ea

Stool smell ;er% foul 6oul

Stool nature Sou% &'reas%

Muc!nous ell% l!e


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Difference &et+een sall &o+el, lar(e &o+el diarr$ea

6eatures Small bowel!arr)ea

Lar'e bowel!arr)ea

Stool t%e (ater% Muco!

5loo !n

stool

Rare *!f

resent "altere,

8ommon *usuall%

" fres) bloo+ !ffrom caecum "maroon coloure


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Lar'e bowel!arr)ea

(58s !nstool

Rare 8ommon

Abom!nal

a!nlocat!on

Per!umb!l!cal

re'!on+ m!abomen*cram% &!nterm!ttent,

Lower abomen

*'r!!n' &cont!nuos,


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Lar'e bowel!arr)ea

Tenesmus Absent Present

7n!'este

mater!al

Ma% be

seen

Inv!s!ble


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Lar'e bowel!arr)ea

Steatorr)ea Ma% beseen

Not seen

6reuenc% Less More


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C"NSTIPATI"N

0 mot!ons er wee or !ff!cult or a!nful efecat!on

8auses$

Low f!bre !et & lac of e4erc!se & !'nor!n' call to

stool Dru's *alum!n!um antac!s+ s%c)otro!c or o!ates,

Irr!table bowel s%nrome

8olon!c carc!noma

D!vert!cular !sease

Anorectal !seases *8ro)n:s !sease+ )emorr)o!s,

Metabol!c B enocr!ne *)%ot)%ro!!sm+

)%ercalcem!a,


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C"L"NIC DISEASE

Pain Local!3e a!n - lower abom!nal uarants

Rectal a!n - ee !n elv!s

Anal canal a!n - accuratel% local!3e !n er!neum

Mec)an!sms of colon!c a!n$

!stent!on from 'as or flu! causes cram% or col!c%a!n from stretc)!n' of muscle la%ers & result!n'contract!on or sasm

Pa!n rel!eve b% assa'e of flatus or stool

Pa!n - !n colon!c wall !nflammat!on or !nf!ltrat!on b% tumor

Acute colon!c !nflammat!on w!t) !nvolvement of v!sceralor ar!etal er!toneum - s)arl% local!3e a!n *ma% beaccoman!e b% abom!nal 'uar!n' & rebountenerness,


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Anal%sis of se-ere a&doinal pain

Abom!nal a!n Small-bowelobstruct!on

S!te 7mb!l!cus

Ra!at!on of a!n N!l

T%e of a!n 8ol!c%

Sever!t% Severe


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Abom!nal a!n Small-bowel obstruct!on

2nset &

urat!on

6a!r% ra! onset & urat!on$

)ours to a%s

A''ravat!n'factors

N!l

Rel!ev!n'factors

N!l


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Abom!nala!n

Small-bowel obstruct!on

Assoc!ate

s%mtoms

;om!t!n'

2n )%s!cale4am!nat!on

8entral!st!nct!on+ !ncreasebowel souns+ f!n'ere4am!nat!on of rectum$ balloone

& emt% rectum *Greov:s s!'n,Invest!'at!ons C-ra%$ !ntest!nal flu! level

*?lo!ber:s cus$ )or!3ontal flu!level & 'as bubble,


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Abom!nal a!n 8omlete lar'e-bowelobstruct!on

S!te


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Abom!nal a!n 8omlete lar'e-bowelobstruct!on

2nset &urat!on

Slow onset+ ma% rolon'efor some a%s

A''ravat!n'factors

N!l

Rel!ev!n'factors

N!l


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Abom!nala!n

8omlete lar'e-bowelobstruct!on

Assoc!ate

s%mtoms

8onst!at!on+

late sta'e - vom!t!n'

2n )%s!cale4am!nat!on

6lan !st!nct!on+ !ncreasebowel souns+ f!n'ere4am!nat!on of rectum$ balloone

& emt% rectum *Greov:s s!'n,

Invest!'at!ons C-ra%$ !ntest!nal flu! level*?lo!ber:s cus$ )or!3ontal flu!

level & 'as bubble,


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C"L"NIC DISEASE

Rectal &leedin(

D!a'nost!c stool aearance$

Blood coating eterior of formed stool " lesion in

anal canal or rectum

Blood admied with feces " bleeding source higherin colon

Bris% hemorrhage from colon or distal small

intestine " #assage of fresh blood (hematoche*ia)+ fresh blood clots " lesion in left colon

dar%, maroon"colored blood " bleeding from right

colon


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P$%sical e.aination in colonic

diseases

Digital rectal eamination (#erianal, s#hinteric

am#ullary lesions, #rostatic uterine

abnormalities, rectal masses metastatic tumor

in #erirectal tissues " Blumers shelf -ecal material on glove " immediate test with

guaiac"im#regnated cards for occult blood


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A&noral stool ! o&/ecti-e e-idenceof colonic disease

Stool e4am!nat!on b% )%s!c!an - as soon as oss!ble afterefecat!on for resence of v!s!ble bloo on surface or w!t)!nt)e sec!men+ test for occult bloo

M!crosco!c e4am!nat!on of fres) stool - !a'nos!s ofaras!t!c !seases *ameb!c col!t!s - mot!le tro)o3o!ts !nfres)+ warm stool susens!on,

Stool susens!on sta!ne w!t) a ro of met)%lene blue forol%mor)onuclear leuoc%tes " !n!cat!on of resence ofacute !nflammator% e4uates *ulcerat!ve col!t!s+ ameb!ccol!t!s & bac!llar% %senter%,

6!4e & sta!ne sl!es of stool for amoebas & ot)eraras!tes

Stool culture - for !a'nos!s of bac!llar% %senter%

Suan III sta!n of stool - screen!n' test for steatorr)ea


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'ARIUM STUDIES

Enteroclysis is a s#eciali*ed small"bowel barium

study during which barium is infused ra#idly via

a nasogastric tube into the !e!unum (techniue

allows distention of bowel loo#s ra#id fillingentire small intestine " avoiding #roblems of

inadeuate distention #oor transit sometimes

encountered in routine small"bowel barium

studies) Enteroclysis " in sus#ected small"bowel lesions

not visuali*ed by ordinary barium study


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'ARIUM , END"SC"PIC

STUDIES

Barium enema " for identification of colonicdiseases (including diverticulosis itscom#lications, motility disturbances,dis#lacement of colon by etrinsic lesion)

Barium enema " for detection of loss of haustralmar%ings in chronic ulcerative colitis fordiagnosis of intestinal fistulas

-ibro#tic colonosco#y " for diagnosis ofinflammatory bowel changes or for detection ofcolonic neo#lasm (with bio#sy of sus#iciouslesion removal of #oly#s)


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SI*M"ID"SC"PY ,

MESENTERIC AN*I"*RAP#Y

A##roimately half of all colorectal neo#lasm

" in distal ./ cm of bowel (fleible fibro#tic

sigmoidosco#es " #ossible to eamine lower

0/"/ cm of colon, rigid sigmoidosco#e " with2. cm limit)

Angiogra#hy for diagnosis of 2 conditions+

intestinal ischemia gastrointestinal

hemorrhage


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RADI"NUCLIED 'LEEDIN*

SCAN Bleeding from small or large bowel can be locali*ed by

radionuclide scanning of the abdomen after 3 in!ection

of technetium 44m sul#hur colloid or autologous red

cell labeled with the same agent

bleeding at rate of /51"/5.ml6min or greater " location ofradioactivity in abdomen may indicate bleeding source

radionuclide bleeding scan " non"invasive, #articular

advantage in older #atients with bleeding from small

bowel or colon bleeding scan is not recommended in #atients with

sus#ected bleeding from eso#hagus, stomach or

duodenum (best studied by u##er endosco#y)


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Ulcerati-e colitis

Cro$n0s disease $rohns disease can affect any #art of 78 from

mouth to anus (9/: "0/: in small intestine

alone, 0/"./: at both #arts, 1."2.: colitis

alone, in 4/: " terminal ileum) $rohns disease " transmural #rocess

;lcerative colitis " mucousal disease that

usually involves rectum etends #roimally to

involve all or #art of colon


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Di(esti-e s%ste e.aination

Lips

Lab!al swell!n' !n 8ro)n:s

!sease *!nflammator% bowel

!sease,

Systemic features: arthritis,iritis, pyoderma

gangrenosum


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Disorders causin( ala&sorption

Coeliac disease 8oel!ac !sease *'luten-sens!t!ve enteroat)%,

" !mmunolo'!call% me!ate !nflammator%

!sorer of small !ntest!ne !n 'enet!call%

suscet!ble !n!v!uals 8ommon !n nort)ern Euroe

Pat)o'enes!s " !mmunolo'!cal resonse to

'luten


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Mala&sorption S%ndroe


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?emato#oietic system+ Anemia ( due to delayed absor#tion of iron, vitamin B12 and folic

acid )

?emorrhagic syndrome ( due to 3it K malabsor#tion andhy#o#rothrombinemia )

@usculos%eletal system + Bone #ain ( due to #rotein de#letion and calcium malabsor#tion

leading to osteo#orosis and osteomalacia )

arasthesias and tetany ( due to hy#ocalcemia andhy#omagnesemia )

ervous system +

>ight blindness and ero#thalmia ( due to 3it A deficiency )

eri#heral neuro#athy ( due to 3it B1 and B12 deficiency )


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'%in + " s%in #u#ura ( due to 3it K deficiency ), dermatitis and follicular

hy#er%eratosis ( due to 3it A and *inc deficiency ) " n general, any combination of weight loss, osmotic small"

intestinal non"inflammatory diarrhea accom#anied bysteatorrhea and anemia ( due to small iron stores, anemia isusually hy#ochromic and microcytic )

aboratory studies + " 8he #resence of fragments of undigested food steatorrhea,

creatorrhea ( for an adult eating a normal diet with an averagedaily fat inta%e of 1//mg, a fecal lost of more than mg #er20hrs is abnormal )

Blood test + " ?b, hematocrit, CB$ count, albumin, cholesterol, calcium, iron,

magnesium and #otassium levels are diminished and#rothrombin time is #rolonged

E t i t ti l fi di i t d


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E.traintestinal findin(s associated

+it$ sall!intestinal diseases

buccal #igmentation or teleangiectasia & in co"

eistent small"bowel #oly#osis or intestinal

teleangiectasia with e#isodes of abdominal #ain

or chronic bleeding evidence of iritis, arthritis, or erythema nodosum

& suggestion of inflammatory bowel disease

MALA'S"RPTI"N


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MALA'S"RPTI"N

La&orator% e.aination

Anemia

?y#o#roteinemia

?y#ocholesterolemia

?y#oglycemia

$o#rological studies+ increased undigested food

content increased ecretion en*ymic food

decom#osition #roducts

intestinal diseases

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