Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Alterations of Digestive.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Vascular Insufficiency  Vascular insufficiency in the intestine is most often associated with occlusion or obstruction of the mesenteric vessels or insufficient arterial blood flow.  Acute insufficiency is usually due to emboli dislodged from the heart.  The resulting ischemia and necrosis produce abdominal pain, fever, bloody diarrhea, hypovolemia, and shock.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Obesity  Obesity is a metabolic disorder with an increase in body fat mass and a BMI greater than 30.  The causes of obesity are complex and involve the interaction of adipokines produced by fat cells and other body weight control signals at the level of the hypothalamus.  Hypothalamic resistance to leptin increases body fat mass.  The gene for leptin is mutated in some obese people.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Obesity  Central obesity increases the risk of developing hypertension, coronary artery disease, type 2 diabetes mellitus, cancer, and pulmonary disorders.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Anorexia Nervosa and Bulimia Nervosa  Characterized by abnormal eating behavior, weight regulation, and disturbed attitudes toward body weight, body shape, and size

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Anorexia Nervosa  Anorexia nervosa is a psychologic and physiologic syndrome characterized by the following:  Fear of becoming obese despite progressive weight loss.  Distorted body image: the perception that the body is fat when it is actually underweight.  Body weight 15% less than normal for age and height because of refusal to eat.  In women and girls, absence of three consecutive menstrual periods.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Anorexia Nervosa  Primarily occurs in adolescent and young women.  Anorexic patients can lose 25% to 30% of their ideal body weight.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Anorexia Nervosa  Clinical manifestations:  Without adequate nutrition, muscle and fat depletion lead to hypotension, edema, bradycardia, hypothermia, and constipation.  Can lead to starvation-induced cardiac failure.  Death may occur if weight loss exceeds 25% of ideal body weight.  Treatment - intensive psychologic intervention; may require hospitalization to restore nutritional balance.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Bulimia Nervosa  Bulimia nervosa, or binging and purging, involves eating normal or large amounts of food and then purging by inducing vomiting or abusing laxatives.  Severe weight loss is rare.  Frequent vomiting and laxative use result in pathological effects.  Often accompanies anorexia nervosa and may have similar psychological causes.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Bulimia Nervosa  Clinical manifestations:  Continual vomiting of acidic chyme can cause pitted teeth, pharyngeal and esophageal inflammation, and tracheoesophageal fistulas.  Overuse of laxatives can cause rectal bleeding.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Portal Hypertension  Portal hypertension is an elevation of portal venous pressure to at least 10mm Hg.  Results from increased resistance to venous flow in the portal vein and its tributaries, including the sinusoids and hepatic vein.  Causes - cirrhosis of the liver (most common); can be seen in congestive heart failure, hepatic vein thrombosis, and infection of the liver.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Portal Hypertension  Pathophysiology:  The portal system consists of a large network of collateral veins that come together to form the portal vein before it enters the liver.  When flow in the portal vein is obstructed, pressures rise and are reflected back to these collateral veins, causing them to dilate and become prone to rupture and hemorrhage.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Portal Hypertension  Consequences:  Esophageal varices - often cause bleeding; rupture can be life-threatening.  Hemorrhoids - varices of the rectum.  Splenomegaly - from increased pressures reflected into the splenic vein.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Portal Hypertension  Consequences: (cont.)  Ascites - increased pressures in the veins in the abdomen cause translocation of fluid from the vessels into the peritoneal space.  Hepatic encephalopathy - CNS disturbances and alterations of consciousness due to toxins in blood that are not removed by the liver.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Ascites  Ascites is accumulation of protein-rich fluid in the peritoneal space.  Causes - hepatic cirrhosis (most common), malignancies, and conditions characterized by reduced intravascular oncotic pressure such as nephrotic syndrome and malnutrition.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Ascites  Pathophysiology:  Liver damage reduces the production of albumin and increases portal venous pressures.  Together these cause capillary hydrostatic pressure to exceed capillary osmotic pressure.  This imbalance pushes water into the peritoneal cavity.  Conditions that impair excretion of sodium by the kidneys promote water retention and add to the volume of fluid that accumulates.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Ascites  Clinical manifestations –  Weight gain due to fluids and increased abdominal girth.  Dyspnea due to pressure on diaphragm.  Vulnerability to peritoneal infection.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Hepatic Encephalopathy  Hepatic encephalopathy is impaired cerebral function caused by blood-borne toxins (particularly ammonia) not metabolized by the liver.  Toxin-bearing blood may bypass the liver in collateral vessels dilated as a result of portal hypertension, or diseased hepatocytes may be unable to carry out their metabolic functions.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Hepatic Encephalopathy  Clinical manifestations - range from memory loss, confusion and asterixis (flapping tremor of the hands) to loss of consciousness, coma, and death.  The condition develops rapidly during fulminant hepatitis or slowly during chronic liver disease.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Jaundice  Jaundice (icterus) is a yellow or greenish pigmentation of the skin or sclera of the eyes caused by increases in plasma bilirubin concentration (hyperbilirubinemia).  Unconjugated bilirubin (UCB) - bilirubin that has not been processed by the liver.  Conjugated bilirubin (CB) - bilirubin that has been linked to glucuronic acid by liver cells.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Jaundice a.Obstructive jaundice 1)Intrahepatic obstructive jaundice  Caused by obstructed bile canaliculi.  Due to liver disease (e.g., hepatitis, cirrhosis).  Results in increased levels of both unconjugated (UCB) and conjugated bilirubin (CB) which build up in the blood.  Stool and urine tend to be light in color because less bilirubin is converted to urobilinogen, which normally gives urine (and to a lesser extent, feces) a yellow color.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Jaundice a.Obstructive jaundice 2)Extrahepatic obstructive jaundice  Caused by obstructed bile ducts outside the liver.  Due to gallstones or tumors.  Results in elevation of conjugated bilirubin (CB).  Bilirubin accumulates proximal to sites of obstruction, enters the bloodstream, and is carried to the skin and deposited, causing yellow color and pruritis (itching).  Stools tend to be light because bile is not entering small intestine, but urine tends to be darker than normal.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Jaundice b.Hemolytic jaundice  Also called prehepatic jaundice.  Caused by excessive red blood cell destruction (hemolysis).  Results from hemolytic crisis (as in sickle cell disease) or hemolytic drugs.  Produces elevated levels of unconjugated bilirubin (UCB).  Higher levels of UCB in the stool and urine cause them to have a darker color.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. ACTIVITY 1. High UCB. a. Intrahepatic obstructive 1. High UCB. a. Intrahepatic obstructive 2. High CB. b. Extrahepatic obstructive 2. High CB. b. Extrahepatic obstructive 3. High CB and UCB. c. Hemolytic 3. High CB and UCB. c. Hemolytic 4. Light stool and urine. 4. Light stool and urine. 5. Dark stool and urine. 5. Dark stool and urine. 6. Light stool, dark urine. 6. Light stool, dark urine. 7. Pruritis 7. Pruritis 8. Anemia 8. Anemia 9. Alcoholism 9. Alcoholism 10. Gallstones 10. Gallstones

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Hepatorenal Syndrome  Hepatorenal syndrome is functional kidney failure caused by advanced liver disease, particularly cirrhosis with portal hypertension.  Renal failure is caused by a sudden decrease in blood flow to the kidneys, usually caused by massive gastrointestinal hemorrhage or liver failure.  Clinical manifestations - oliguria, ascites, hypotension, jaundice, and gastrointestinal bleeding.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Viral Hepatitis  Hepatitis - any inflammatory process affecting the liver.  Most commonly describes viral infection of the liver by one of five viruses.  Causes hepatic cell necrosis, Kupffer cell hyperplasia, and infiltration of liver tissue by mononuclear phagocytes.  These changes obstruct bile flow and impair hepatocyte function.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Viral Hepatitis  Most acute infections are followed by regeneration and recovery.  Persistent infection and inflammation, fulminant hepatitis, and even death can occur.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Hepatitis A  Formerly known as infectious hepatitis.  Results from ingestion of contaminated water or food.  Relatively short incubation period (30 days).  Causes an acute, relatively mild illness, usually followed by complete recovery.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Hepatitis A  Clinical manifestations - predictable phases that depend on the stage of infection.  Prodromal phase - fever, malaise, anorexia, and liver enlargement and tenderness.  Icteric phase - jaundice, enlarged liver, hyperbilirubinemia (causes dark urine and stools).  Recovery phase - symptoms resolve. Recovery takes several weeks.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Hepatitis B  Formerly known as serum hepatitis.  Results from exposure to contaminated blood and body fluids, often through sexual contact, needlestick injury, or intravenous drug use.  Incubation period 60-180 days.  The initial phase of infection can be acutely symptomatic or insidious.  Diagnosed by presence of hepatitis B surface antigens (HBsAg).

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Hepatitis B  Pathophysiology:  Hepatic injury is due to immune response to viral antigen in hepatocytes.  A vigorous immune response increases acute symptoms but decreases chronic infection.  Weakened immunity causes fewer acute symptoms but a greater risk of chronic infection and being a carrier.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Hepatitis B  Chronic active hepatitis B is characterized by continued inflammation and the risk for the development of cirrhosis and hepatocellular carcinoma.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Hepatitis C  HCV is acquired through the same routes as hepatitis B.  Responsible for most cases of hepatitis due to blood transfusion and IV drug use.  Rarely causes acute illness.  Up to 80% of infected individuals develop chronic HCV infection, and up to 20% of these progress to cirrhosis and liver failure.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Hepatitis C  HCV infection is a common reason for liver transplantation.  HCV is directly cytopathic to hepatocytes and results in persistent inflammation and progressive scarring.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Fulminant Hepatitis  Clinical syndrome of severe impairment or necrosis of liver cells and potential liver failure.  Complication of hepatitis B or C virus, congenital disorders or toxic reactions to drugs or poisons.  Causes widespread hepatic necrosis and is often fatal.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Fulminant Hepatitis  Clinical manifestations - initially: anorexia, vomiting, abdominal pain, and progressive jaundice; followed by ascites, gastrointestinal bleeding and hepatic encephalopathy; renal failure and pulmonary distress can occur.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Cirrhosis  Cirrhosis is an irreversible inflammatory disease of the liver that disrupts liver function.  Results in disorganization of lobular structure, fibrosis, and nodular regeneration.  Cirrhosis obstructs biliary channels and causes portal hypertension.  Hypertension shunts blood away from the liver, and a hypoxic necrosis develops.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Cirrhosis  Causes - hepatitis or toxins, such as acetaldehyde (product of alcohol metabolism).  Progressive irreversible liver damage occurs, usually over a period of years.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Cirrhosis a.Alcoholic liver disease  Acetaldehyde damages hepatocytes and impairs their ability to oxidize fatty acids, synthesize enzymes and proteins, degrade hormones, and clear portal blood of ammonia and toxins.  The inflammatory response includes excessive collagen formation, fibrosis, and scarring, which obstruct bile canaliculi and sinusoids.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Cirrhosis a.Alcoholic liver disease  Bile obstruction causes jaundice.  Vascular obstruction causes portal hypertension, shunting, and varices.  Hepatocyte damage interferes with production of clotting factors, causing bleeding.  Fatty liver is a mild form of alcoholic liver disease. Asymptomatic and reversible.  Damage in severe disease is irreversible, and often requires liver transplant.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Cirrhosis b.Biliary cirrhosis  Cirrhosis that begins in the bile canaliculi and ducts. 1)Primary biliary cirrhosis - autoimmune inflammation results in destruction of intrahepatic bile ducts.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Cirrhosis b.Biliary cirrhosis 2)Secondary biliary cirrhosis - develops from prolonged obstruction of bile flow.  Obstruction increases pressure in the hepatic bile ducts, causing pooling of bile and necrosis of tissue.  Relief of obstruction allays symptoms of jaundice and pruritus.  Continued obstruction causes cirrhosis and liver failure.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. ACTIVITY a. Alcoholic cirrhosis b. Primary biliary cirrhosis c. Secondary biliary cirrhosis 1. Caused by autoimmune disorder. 1. Caused by autoimmune disorder. 2. Caused by toxins like acetaldehyde. 2. Caused by toxins like acetaldehyde. 3. Caused by blockage of bile flow. 3. Caused by blockage of bile flow. 4. Fatty liver is early stage. 4. Fatty liver is early stage. 5. Involves destruction of liver bile ducts. 5. Involves destruction of liver bile ducts. 6. Reversible if obstruction is relieved. 6. Reversible if obstruction is relieved.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Disorders of the Gallbladder Cholelithiasis  Cholethiasis is the accumulation of gallstones in the gallbladder.  Affects up to 20% of individuals in developed countries.  Risk factors - obesity, middle age, female gender, Native American ancestry, and gallbladder, pancreas, or ileal disease.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Disorders of the Gallbladder Cholelithiasis  Gallstones form in the bile as a result of the aggregation of cholesterol crystals (cholesterol stones; most common) or precipitates of unconjugated bilirubin (pigmented stones).  Gallstones that fill the gallbladder or obstruct the cystic or common bile duct cause abdominal pain and jaundice.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Disorders of the Gallbladder Cholelithiasis  Clinical manifestations - colicky abdominal pain that is intermittent and often associated with fatty food intake; jaundice occurs if stone lodges in common bile duct.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Disorders of the Gallbladder Cholecystitis  Cholecystitis is an inflammation of the gallbladder wall.  It is usually associated with obstruction of the cystic duct by gallstones.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Disorders of the Pancreas Acute pancreatitis  Inflammation of the pancreas.  Causes - obstruction of the pancreatic duct by a gallstone (most common); heavy alcohol intake.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Disorders of the Pancreas Acute pancreatitis  Pathophysiology:  Damaged pancreas cells leak digestive proenzymes into pancreatic tissue.  Proenzymes become activated and begin the process of autodigestion, which causes inflammation, and destruction of tissues.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Disorders of the Pancreas Acute pancreatitis  Pathophysiology: (cont.)  Release of pancreatic enzymes and inflammatory mediators into the bloodstream or abdominal cavity can result in the systemic inflammatory response syndrome (SIRS) with renal, pulmonary, and myocardial dysfunction.  Release of vasoactive inflammatory mediators can cause systemic vasodilation and shock.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Disorders of the Pancreas Acute pancreatitis  Clinical manifestations - severe epigastric pain, fever, nausea, and vomiting; elevated levels of pancreatic enzymes in blood serum, including pancreatic lipase and amylase.  Treatment - often difficult; includes narcotic pain control, eliminating oral intake of food and fluids, parenteral fluids and nutrition, antacids, and antibiotics.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Disorders of the Pancreas Chronic pancreatitis  Chronic pancreatitis results from repetitive inflammation of the pancreas.  Related to chronic alcohol abuse.  Chronic inflammation and scarring of the pancreas cause insulin deficiency and pancreatic insufficiency, with associated digestive problems.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Disorders of the Pancreas Chronic pancreatitis  Clinical manifestations - severe abdominal pain, malabsorption of fat with steatorrhea, and diabetes.  Chronic pancreatitis is a risk factor for pancreatic cancer.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Cancer of the Gastrointestinal Tract Esophageal cancer  Esophageal carcinoma is rare.  Risk factors - age older than 70; alcohol and tobacco use; reflux esophagitis, and nutritional deficiencies.  Clinical manifestations - dysphagia and chest pain are the primary manifestations.  Early treatment of tumors that have not spread into the mediastinum or lymph nodes results in a good prognosis.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Cancer of the Gastrointestinal Tract Stomach cancer  Risk factors - H. pylori infection, high salt intake, food preservatives (nitrates, nitrites), alcohol and tobacco use, and atrophic gastritis.  Approximately 50% of all gastric cancers are located in the prepyloric antrum.  Clinical manifestations - weight loss, upper abdominal pain, vomiting, hematemesis, anemia; these develop only after the tumor has penetrated the wall of the stomach.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Cancer of the Gastrointestinal Tract Colon and rectal cancer  Cancer of the colon and rectum (colorectal cancer) is the third most common cause of cancer death in the United States.  Risk factors - advanced age; colon polyps and hereditary polyposis, smoking, high-fat low-fiber diet, alcohol consumption, obesity, and ulcerative colitis.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Cancer of the Gastrointestinal Tract Colon and rectal cancer  Clinical manifestations - gradual onset of changes in bowel movements, melena or hematochezia, weight loss, abdominal pain, and bowel obstruction.  Rectal tumors can spread transmurally to the vagina in women or prostate in men.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Cancer of the Gastrointestinal Tract Liver cancer  Metastatic invasion of the liver is more common than primary cancer of the liver (hepatocellular carcinoma).  Risk factors- ingestion of mycotoxins found in moldy grain, cirrhosis, hepatitis B and C virus, and alcohol abuse.  Clinical manifestations - abdominal discomfort, nausea, and fullness in the right upper quadrant; jaundice may occur early or late depending on the type of neoplastic changes.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Cancer of the Gastrointestinal Tract Pancreatic cancer  Pancreatic cancer is the most deadly form of cancer, with a mortality rate of almost 100%.  Risk factors - smoking, diabetes, and chronic pancreatitis.  Cancer usually arises from the exocrine cells and rapidly invades surrounding tissue and abdominal structures.  If the tumor occurs in the head of the pancreas, individuals may present with bile duct obstruction ("painless jaundice").

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Cancer of the Gastrointestinal Tract Pancreatic cancer  Metastasis to other organs occurs early in the course of the disease.  Clinical manifestations - generally few symptoms until late in the course of the illness, though abdominal or back pain may be present; symptoms more often result from metastases to the brain, lungs, or lymph nodes.

Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Alterations of Digestive.

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Elsevier items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published. Alterations of Digestive.

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