miscellaneous topics in gastroenterology - jmc.gov.jo · pdf file•h. pylori was...
TRANSCRIPT
![Page 1: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/1.jpg)
Miscellaneous Topics in
Gastroenterology
Waseem Hamoudi M.D
Consultant Internal Medicine
Gastroenterology & Hepatology
![Page 2: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/2.jpg)
• Peptic Ulcer Disease.
• Inflammatory Bowel Disease.
• Acute diarrhea.
![Page 3: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/3.jpg)
Peptic Ulcer Disease
• Peptic ulcerations are excavated defects (holes) in the gastrointestinal mucosa that result when epithelial cells succumb to the caustic effects of acid and pepsin in the lumen.
• Peptic ulcer disease commonly used term to refer to ulcerations of the stomach, duodenum, or both, that is caused by acid-peptic injury.
![Page 4: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/4.jpg)
• Histological, ulcers are necrotic mucosal
defects that extend through the muscularis
mucosa and into the submucosa or deeper
layers.
• More superficial necrotic defects are
named erosions.
![Page 5: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/5.jpg)
History
• In the early part of the 20th century, stress and diet were considered to be the pathogenetic factors for PUD, so treatment was with bed rest and diet.
• 1950, clinicians had focused their attention on the pathogenetic role of gastric acid, so antacid therapy had become the treatment of choice.
• 1970, histamine H2 receptor antagonists became available, and acid suppression with antisecretory therapy was the treatment of choice for UD.
• 1980, proton pump inhibitors (PPI) were discovered, with more potent acid suppression and higher rates of ulcer healing.
• Using alone antisecretory drugs, will have recurrence within one year in most patients
![Page 6: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/6.jpg)
• H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren.
• In 1983 the two doctors proposed that the bacterium is the cause of peptic (duodenal and gastric) ulcers.
• Dr. Marshall even went so far as to inoculate himself with the bacterium to prove his point.
• it soon became apparent just how widespread and serious the H. pylori threat is.
• Researches confirm that over 90 per cent of people with peptic ulcers are infected with the bacterium.
• In 1987 the Sydney gastroenterologist Thomas Borody invented the first triple therapy for the treatment of duodenal ulcers.
![Page 7: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/7.jpg)
![Page 8: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/8.jpg)
Causes
• United Kingdome United states
• Duodenal ulcer Peptic ulcer disease
• Gastric ulcer( Benign) Gastroesophageal
varices
• Esophagitis Angiomas
• Mallory-Weiss tear Mallory-Weiss tear
• Gastroesophageal varices Tumors
• Gastritis or gastric erosions Erosions
• Tumors Dieulafoy's lesion
![Page 9: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/9.jpg)
Jordan (Al Bashir Hospital)
• Duodenal ulcer 41.90%
• Esophageal varices 16.07%
• Erosive gastritis/duodenitis 14.09%
• Esophagitis 8.64%
• Gastric ulcer 5.87%
• Gastric and duodenal ulcers 3.60%
• Esophageal ulcer 3.25%
• Anastomotic ulcer 2.26%
• Mallory-Weiss tear 1.55%
• Esophageal tumor 1.41%
• Gastric tumor 1.27%
Waseem H. et al. Upper G.I Bleeding in Jordan- Retrospective statistical analysis 1996-2000
![Page 10: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/10.jpg)
• Peptic Ulcer Disease.
• Inflammatory Bowel Disease.
• Acute diarrhea.
![Page 11: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/11.jpg)
Main types of inflammatory bowel
disease (IBD)
• Ulcerative colitis
• Crohn’s disease
![Page 12: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/12.jpg)
Endoscopic features of ulcerative colitis
(reproduced with permission, Schiller et al, 1986)
![Page 13: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/13.jpg)
Anatomical location of ulcerative colitis
![Page 14: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/14.jpg)
Intestinal complications of
ulcerative colitis
• Fibrosis
• Shortening of the colon
• Bleeding
• Stricture
• Bowel perforation
• Toxic megacolon
![Page 15: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/15.jpg)
Systemic complications of
ulcerative colitis
• Arthritis
• Iritis
• Erythema nodosum
• Pyoderma gangrenosum
• Sclerosing cholangitis
• Aphthous stomatitis
• Thromboembolic disorders
![Page 16: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/16.jpg)
Clinical presentation of
ulcerative colitis
• Bloody diarrhoea
• Fever
• Cramping abdominal pain
• Weight loss
• Frequency and urgency of defecation
• Tenesmus
• General malaise
![Page 17: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/17.jpg)
(reproduced with permission, Schiller et al, 1986)
Endoscopic appearance of Crohn’s
disease
![Page 18: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/18.jpg)
Anatomical location of Crohn’s disease
![Page 19: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/19.jpg)
Clinical presentation of Crohn’s
disease
• Diarrhoea
• Abdominal pain
• Bleeding
• Pyrexia
• Weight loss
• Fistulae
• Perianal disease
• General malaise
![Page 20: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/20.jpg)
Intestinal complications of
Crohn’s disease
• Fistulae
• Abscesses
• Adhesions
• Strictures
• Obstruction
![Page 21: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/21.jpg)
Perianal complications of Crohn’s disease
![Page 22: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/22.jpg)
Systemic complications of
Crohn’s disease
• Arthritis
• Gallstones
• Malabsorption
– Lactase deficiency
– Vitamin B12 deficiency
• Renal stone formation
![Page 23: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/23.jpg)
Differences in clinical presentation between ulcerative
colitis and Crohn’s disease
Ulcerative colitis Crohn’s disease
Symptoms
Pain * * * *
General malaise * * * * *
Fever * *
Diarrhoea * * * *
Stools
Blood * * * *
Mucus * * *
Pus * * *
The number of * symbols indicates the frequency with which
each symptom is present
![Page 24: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/24.jpg)
Pathological and anatomical features distinguishing
ulcerative colitis from Crohn’s disease
Ulcerative colitis Crohn’s disease
Localisation Distal Segmental,
proximal
Rectum affected Always 50% of cases
Intestinal wall Normal thickness Thickened
Adhesions Rare Common
Inflammation Superficial layers All layers
Ulcerations Superficial Deep
Mucous membrane Denuded Cobblestones
Granulomas 0–4% 50–70%
Lymphocytic infiltration Rare Always
Fistulae Rare Common
![Page 25: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/25.jpg)
(reproduced with permission, the AGA Teaching Project, 1992)
Geographical distribution of IBD
![Page 26: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/26.jpg)
Etiological theories of IBD
• Genetic
• Smoking
• Dietary
• Infection
• Immunological
• Psychological?
![Page 27: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/27.jpg)
Pharmacological treatment of IBD
• 5-ASA-containing compounds – mesalazine
Pentasa®
Asacol®
Claversal®/Mesasal®/Salofalk®
– sulphasalazine Salazopyrin®
– olsalazine Dipentum®
• Corticosteroids
• Immunosuppressants
![Page 28: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/28.jpg)
Treatment: indications for
surgery
• Perforation
• Toxic dilatation
• Massive haemorrhage
• Chronic ill-health
• Risk of cancer
![Page 29: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/29.jpg)
• Peptic Ulcer Disease.
• Inflammatory Bowel Disease.
• Acute diarrhea.
![Page 30: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/30.jpg)
• Normally 10 liters enter the duodenum daily, of which 1 liter is absorbed by the small intestine.
• Colon resorbs most of the remaining fluid with only 100 ml fluids lose in the stool.
• Medical definition of diarrhea: a stool weight more than 250 g/day.
• Practical definition: increased stool frequency more than 3 times/day or liquidity.
• There are 2 types of diarrhea: acute diarrhea (less than 3 weeks) and chronic diarrhea (more than 3 weeks).
![Page 31: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/31.jpg)
![Page 32: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/32.jpg)
Acute diarrhea
• Acute diarrhea: acute onset of diarrhea
and present for less than 3 weeks
• Mostly caused by infectious agents,
bacterial toxins (ingested preformed in
food or produced in gut) and drugs.
• Similar recent illness in family members
suggests an infectious etiology.
![Page 33: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/33.jpg)
Non-inflammatory diarrhea
• Fever absent.
• Stool without blood or fecal leucocytes.
• Watery stool with peri-umbilical cramps, bloating, nausea and vomiting (small bowel enteritis) caused by either a toxin or other a toxin producing toxin or other agents that disrupt the normal absorption and secretory process in the small intestine.
![Page 34: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/34.jpg)
How do we recognize non-
inflammatory diarrhea?
By examining the absence of the
leucocytes in the stool
![Page 35: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/35.jpg)
What are the causes of Non-
inflammatory diarrhea?
• Viral: Norwalk virus, Rotavirus.
• Protozoa: Giardia lamblia, Cryptosporidium.
• Bacterial:
• Preformed entero-toxins: Staphylococcus aureus, Bacillus cereus, and Clostridium perfringens.
• Intra-intestinal enterotoxin production: E. coli (enteropathogen) and Vibrio cholera.
• New medication.
• Fecal impaction.
![Page 36: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/36.jpg)
Inflammatory diarrhea
• Presence of fever and bloody diarrhea
(dysentery) indicates colonic damage caused by
invasion (shigellosis, salmonellosis, yersinia and
amibiasis) or a toxin (C.difficile, E. coli 0157:H7).
• Colonic diarrhea is a small amount diarrhea in
volume (< 1l/day) and associated with left lower
quadrant cramps, urgency and tenesmus.
• Fecal leucocytes are present in infections with
invasive organisms.
![Page 37: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/37.jpg)
How do we recognize inflammatory
diarrhea?
By examining the presence of the
leucocytes in the stool
![Page 38: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/38.jpg)
What are the causes of
inflammatory diarrhea? • Viral: Cytomegalovirus.
• Bacterial:
1. Cytotoxin production: E. coli 0157:H7 (enterohemorhagic), Vibrio parahemolyticcus and Clostridium difficile.
2. Mucosal invasion: Shigella, Salmonella, enteroinvasive E. coli, aeromonas and Yersinia.
3.Bacterial proctitis: Chlamydia, N. gonorrhea.
• Protozoa: E. histolytica.
• Other: Ischemic colitis, I.B.D. and radiation colitis.
![Page 39: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/39.jpg)
![Page 40: Miscellaneous Topics in Gastroenterology - jmc.gov.jo · PDF file•H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. •](https://reader034.vdocuments.mx/reader034/viewer/2022051722/5aa9255d7f8b9a7c188c6c8a/html5/thumbnails/40.jpg)