1. GIT 2 New Dr. Basu

2. Topic Malabsorption Diarrhea and Dysentery IBD –Ulcerative colitis –Crohns disease

3. Malabsorption : Classification Diagnosis: Steatorrhea, fat soluble vitamin Deficiency, protein and other deficiency. 1.Celiac sprue 2.Whipple disease 3.Disaccharide deficiency

4. Celiac sprue (chronic sprue) Antigen involved: gluten. Genetic- HLA-DQ2 or HLA-DQ8. MorphologyAtrophy of Villi, increased number of intraepithelial lymphocytes ( CD4 and CD8 cells). ClinicalDiarrhea, flatulence, weight loss, and fatigue, dermatitis Respond to gluten free diet.

5. Atrophy of Villi Normal Complication of celiac sprue: Dermatitis Herpitiformis and NHL.

6. Tropical sprue Definition : malabsorption due to unknown ( ? Infection) etiology. Location: Caribbean and South America Treatment: antibiotics and B12 supplements.

7. WHIPPLE DISEASE Etiology: Bacterium Tropheryma whippelii MorphologyMacrophages contain PAS- positive, diastase-resistant granules and rod-shaped bacilli on electron microscopy Other organ involvement GIT, CNS, Joint and lymph nodes

8. Clinical Features Age: 40-50 yr. Malabsorption, Arthropathy, psychiatric complaints and Lymphadenopathy.

9. Electron microscopy Light microscope (H&E) Foamy macrophage in villi.

10. LACTASE DEFICIENCY Etiology : Atrophy of the apical villous cells> deficiency of lactase. Clinical : The infants develop explosive, watery, frothy stools and abdominal distention. Osmotic diarrhea with milk product. Termination of which result in recovery.

11. Vitamin deficiency Vitamin ANight blindness, xerophthalmia, blindness, Squamous metaplasia, infection. Vitamin KBleeding diathesis- not corrected by k injection. Vitamin DRickets in children, Osteomalacia in adults. Vitamin ESpinocerebellar degeneration Vitamin B12Megaloblastic pernicious anemia and myelin loss of spinal cord tracts.

12. DIARRHEA AND DYSENTERY

13. DIARRHEA Def; An increase in stool mass, stool frequency, and/or stool fluidity are perceived as diarrhea. DYSENTERY: Dysentery is a severe diarrhea illness often associated with blood in the feces.

14. Diseases Viral enterocolitisRota virus (dsRNA): child and self limiting. Adenovirus (dsDNA): adult /child E. coli - Shiga-like toxin (Undercooked beef products: hamburger) Hemorrhagic colitis and Hemolytic-Uremic syndrome (HUS): Hemolysis, Acute Renal failure and DIC.

15. Others Staphylococcus aureas : –Source is milk product and fatty food → Acute explosive Exudative diarrhea. –Within a few hours (1-6 hr) Vibrio cholera: –Source is Water → Watery diarrhea, cholera, pandemic spread. –Morphology of GI: normal mucosa

16. Cholera: pathogenesis of diarrhea Cholera toxin A1 ↓ A1+ ADP-ribosylation factors (ARF) ↓ catalyzes G protein ↓ stimulates adenylate cyclase ↓ high levels of intracellular cAMP ↓ stimulates secretion of chloride and bicarbonate, with associated sodium and water secretion.

17. Others Salmonella enteritidis→ Milk, beef, eggs, poultry Self limiting diarrhea / dysentery pain, bacteremia. Incubation: 12 to 72 hr Shigella: Person-to-person. Milk, poultry S. flexneri infection produce Reiter syndrome (chronic arthritis, red eye- conjunctivitis). Fever, pain, mucosal ulcer. Exudative diarrhea,dysentery, epidemic spread

18. Clostridium difficile Clostridium difficile → Following antibiotic use, nosocomial acquisition: Cytotoxin, local invasion Fever, pain, bloody diarrhea, pseudo membrane formation over mucosa. Neural reflex pathways increases epithelial fluid secretion In addition to production intracellular cAMP

19. Pseudomembranous colitis from C. difficile infection morphology Study unknown picture

20. Campylobacter Enterocolitis Source: dog, ingestion of improperly cooked chicken. Clinical: Diarrhea, dysentery. Complications: Reactive arthritis in HLA-B27 carriers Guillain-Barré syndrome- myelin loss (PNS). C. jejuni: immunoproliferative small intestinal disease.

21. Amebiasis AgentEntamoeba histolytica (ameba) RouteFecal oral MorphologyProduce flask shaped ulcer in submucoca. Clinical features Abdominal pain, bloody exudative diarrhea, or weight loss and amebic liver abscess- right upper Q pain.

22. Rest a while

23. Other intestinal disorders Necrotizing Enterocolitis Idiopathic Inflammatory Bowel Disease

24. Necrotizing Enterocolitis Definition An acute, necrotizing inflammation of the small and large intestines AgeNeonate : premature or of low birth weight, when infants are started on oral foods

25. Necrotizing Enterocolitis Pathogenesis: factor Intestinal ischemia Clinical course : Bloody stools, abdominal distention, and development of circulatory collapse. Site: involves the terminal ileum, cecum, and right colon.

26. Morphology of the gut: gross and micro Distended, friable, and congested, or it can be frankly gangrenous. Accompanying peritonitis may be seen. Morphology: sub mucosal gas bubbles formation.

27. Distended intestine Submucosal gas bubbles

28. Prognosis High mortality Post-NEC stricture is COMMON.

29. Idiopathic Inflammatory Bowel Disease Type Pathogenesis Comparative morphology of these two diseases Complications and clinical features Diagnosis

30. IBD Types: –Crohns disease –Ulcerative colitis Pathogenesis: A.Exaggerated local CD4 T-Cell immune response- damage to mucosa B.Inflammation

31. Crohn disease Features: –Occur any part of GIT –Transmural inflammation. –Noncaseating granulomas. –Fissuring with formation of fistulae. –Smoking is a risk factor. –Recurrent diarrhea, pain, fever common. –Blood in stool 50%.

32. Ulcerative colitis Features: –Disease limited to the colon and affecting only the mucosa and sub mucosa. –Smoking is a risk factor. –Bloody mucoid diarrhea more common.

33. Gross Crohn disease ( gross)Ulcerative colitis ( gross) Any part of bowel : common in ileocecal junction (regional ileitis) Large intestine: Pan colitis. Rectum→ colon: back wash ileitis Produce “skip” lesions. Transmural inflammation. No skip lesion, entire length of bowel is involved. Mucosal involvement Cobblestone effectPseudo polyps

35. Gross Crohn disease ( gross)Ulcerative colitis ( gross) Diseased wall is rubbery and thick Mural thickening does not occur in UC Linear ulcerationBroad-based ulceration Mesenteric fat wraps around the bowel surface (creeping fat). No such features

36. Crohn disease : Diseased wall is rubbery and thick and lumen is narrow that give rise to String sing on X-ray Study unknown picture

37. Gross of Ulcerative colitis :Pseudopolyps

38. Microscopy of IBD Crohn diseaseUlcerative colitis Non Caseating granuloma Crypt abscess Pseudopolyps Dysplasia +

39. Ulcerative colitis; crypt abscess and glandular architectural distortion and dysplasia. Study unknown picture

40. IBD: complication Ulcerative colitisCrohn's Complication: Toxic megacolon Adenocarcinoma. Complication: Fistula and fissure, obstruction Fistula with other organ like U. Bladder, vagina and, skin (Enteroculaneous fistula)

41. Toxic mega colon in UC No motility, lead pipe

42. Crohn disease: Fissure

43. Extra intestinal manifestation of IBD Crohn diseaseUlcerative colitis Migratory poly arthritis ++. Aphthous ulcer. Migratory poly arthritis ++++ Uveitis++++++++ Erythema nodosum (painful skin lesion- show similar granuloma) Hepatic primary sclerosing Cholangitis +++++++

44. Diagnosis/ treatment of IBD Crohn diseaseUlcerative colitis Surgery not helpfulSurgery helpful with steroid pANCA : +pANCA: ++++++++, HLA B27

45. Irritable Bowel Syndrome Intrinsic motility disorder ( ? Due to foods, stress- serotonin). Clinical: altered bowel habits, frequently suffering from constipation, diarrhea, or both. The episodes may subside with a bowel movement

46. Thank you