Lecture 30 January 26th-gi

1DDX: LECTURE 30 – JANUARY 26TH 2007 GASTROINTESTINAL DISORDERS: LIVER Page 1 INTESTINAL DYSBIOSIS Hypochlorhydria: many bacteria can survive and disrupt flora Bloating and gas are very prevalent Page 2 MALDIGESTION AND MALABSORPTION With decreased bone mineralization, look for osteoporosis, teeth problems. With bowel resection: decreased surface area. Radiation enteritis: abdominal: with bowel tumor, patient will have more focused and deeper radiation. Affects bowels, causes enteritis, sometimes ulcerations of skin and bowels. Page 3 DIVERTICULOSIS: DUODENAL DIVERTICULA Get GI bleeding if food gets stuck, causes ulceration and erosion of blood vessels. JEJUNAL DIVERTICULA Larger than duodenal diverticula: therefore more problems. MECKEL’S DIVERTICULUM Can contain stomach or pancreatic tissue: this may produce large amounts of HCl: signs of hyperchlorhydria. Congenital anomaly. It is a true diverticulum: contains all layers of tissue. Note complication: peptic ulceration, especially if it contains ST tissue: will produce HCl. If it is big enough to twist, strangulate, may have these complications (won’t happen with small diverticulum) COLON DIVERTICULA • Not a true diverticulum: only contains mucosa. • Vegetarians have 1/3 incidence of diverticulosis: fibre is an important factor. • Usually no clinical picture: they won’t be aware. Will see symptoms when there is inflammation, when it becomes diverticulitis. • Advise patient to have smaller meals: less increase in luminal pressure. • Most important complication in diverticulitis: further complications are more likely to come from this. Page 4 DIVERTICULITIS: • Food sits in the sack formed by the diverticulum until it gets infected.

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Fecalith: A hard stony mass of feces. Usually LLQ pain: was called “left-sided appendicitis” b/c signs and symptoms are the same. If it occurs on the R, or if the signs of appendicitis occur on the left (see PCD notes), you may not be able to diagnose without surgery. Can form fistula and drain into bladder or vagina… many complications from this. Usually painless bleeding, but with large amounts of blood. Diverticular bleeding: usually is from the R side of the colon, vs. diverticulitis, which usually involves the left side of the colon. Dx through arteriography.

Page 5 Picture of ruptured diverticulum: there is necrosis in this example. Rupture spills the contents into the abdominal cavity: septicemia MEGACOLON • One of the most important causes of megacolon is Hirschprung’s Disease • Congenital problem. • Meconium: Baby's first bowel movement, this is the greenish substance that builds up in the bowels of a growing fetus and is normally discharged shortly after birth • Pathognomonic sign: digital-rectal exam reveals absence of stool in the rectum. Rectum biopsy confirms the diagnosis. • Only solution is surgical. Page 6 CHRONIC IDIOPATHIC MEGACOLON/PSYCHOGENIC MEGACOLON • Normal mucosa, child refuses to have a bowel movement. Digital-rectal exam will reveal stool in the rectum. • This will also happen in bedridden elderly: They can’t get up to have a bowel movement on their own. • Feces can become impacted, have to be removed manually (with a gloved hand) CHAGA’S DISEASE • Another type of acquired megacolon: d/t infection with Trypanosmoa cruzi. Destroys ganglion cells of colon. • In severe neurologic disorders: does not DESTROY the ganglion. Impairs it, but it is still detectable. • To treat: want to get to source of problem. This is very difficult for patients on morphine: can’t take away their pain killers (cancer patients for example)

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INTESTINAL OBSTRUCTION MECHANICAL OBSTRUCTION/DYNAMIC ILEUS • Can be internal or external. • Volvulus: intestinal obstruction due to twisting of bowel. • Carcinoma + diverticulitis + volvulus = 90% of cases. • On x-ray will see dilated bowels. Everything above obstruction will be filled with gas and liquid. NON-MECHANICAL OBSTRUCTION / ADYNAMIC ILEUS • This is like a paralysis of the intestine: no peristalsis to move the bowels. • Will occur to some degree after any abdominal operation: bowels respond with some paralysis. • Other causes are retroperitoneal hematomas esp. if associated with vertegral fracture (might impact the innervation of the bowel) • Electrolyte disturbances: potassium is involved with contraction. See DDX chart on pg. 6 • Paralysis of ileus: silent. No peristalsis, lots of gas accumulating: distention/tympany. • Pathognomonic imaging sign: bow-shaped loops in ladder pattern (Mechanical obstruction). Also note air-fluid levels. Page 7 INTESTINAL OBSTRUCTION • Higher the obstruction = more pain. The intestine has to work harder to move contents if higher up. • Higher obstruction: more severe vomiting after eating. If the obstruction is lower, there won’t be as much vomiting. • Abdomen may be soft, but may be hard in places as well (gas). • *Absence of colonic gas: there is nothing getting to the large intestine. Will see this on x-ray. LARGE BOWEL OBSTRUCTION Very low obstruction. Not usually vomiting, but constant nausea. Severe constipation, a little pain, distended abdomen and nausea: these are common symptoms of colon cancer that will present in the ER. This could be the first sign of colon cancer: caused by obstruction. No bleeding, nothing major. Came to ER when obstruction was almost complete. APPENDICITIS • Symptoms may be variable as the location of the appendix is somewhat variable. • Becomes infected: this is when you see the signs of appendicitis. • Absence of leukocytosis does not rule out appendicitis. May not have had time to occur. • Familial Mediterranean fever may present like appendicitis (this was discussed in one of our first lectures.) May have appendix removed prophylactically so that the next time that they present with these symptoms, it is certain that it is not appendicitis. Page 8 • Biliary colic an colecystitis: BC: Typically RUQ pain, radiate to back or right shoulder. Ultrasound might reveal biliary pathology. • Gastroenteritis: Vomiting and intense diarrhea. Don’t have this in appendicitis. • Ovarian cysts/torsion, rupture: The pain can be the same, but with a ruptured ovarian cyst, there will be more signs of shock. Ultrasound will differentiate between the 2. • Mesenteric ischemia: This will usually occur if there is a known underlying condition: more likely in adult/elderly. Appendicitis is more common in younger population. • Pelvic Inflammatory Disease: Mostly in women. • Renal calculi: The pain would be more in the back than in the abdomen, ultrasound will reveal the calculi • Urinary tract infection: Urinalysis will DDX • Endometriosis: Pain will occur mostly during menses. Sometimes diagnosed by ultrasound, but not always. Only DDX is by laparoscopy: the insertion of a thin lighted instrument (a laparoscope) through the abdominal wall to inspect the inside of the abdomen and perform biopsies. • Inflammatory bowel disease: Can be hard to DDX. • Pancreatitis: In children, this can be mid-abdominal pain. Blood test. ABDOMINAL PAIN: How to DDX different types. There are life threatening causes: have to know what they are. Appendicitis: can be life-threatening if there is rupture. Other conditions under “origins of abdominal pain” can be life threatening if they progress, or if there are complications. At our clinic, survey done, and 60% of clinic patients use the clinic for primary care (don’t have another physician). We have to know signs of emergency. Sweating can be a sign of shock: being quiet too. In ER: go to patient that is lying still first: they are probably in shock. Chronic/recurrent abdominal pain: Why would you have recurrent bowel obstruction? People who have repeated abdominal surgeries and develop fibrotic bands, they may have recurrent bowel obstruction. Will have adhesions, bands after each surgery, obstruct bowels. How to DDX abdominal distention: 5 x “fs”: these are the 5 reasons why you would have a distended abdomen. IRRITABLE BOWEL SYNDROME (IBS) A diagnosis of exclusion: rule out the other possibilities, and what is left is IBS. Most symptoms occur while awake. May not find anything pathologic on physical examination. Page 9

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Usually even colonoscopy is normal. Not recommended unless there is change, or if the patient is at risk for other conditions. As naturopaths we can do a lot for these patients. IRRITABLE BOWEL DISEASE (IBD) Symptoms can vary… CROHN’S DISEASE • Aka regional enteritis. • Skip lesion: pathognomonic • Transmural inflammation: the whole wall of the ileum is inflamed. This can lead easily to complications. • Enterocolic fistula: between small and large intestine, between intestine and vagina. • On and off: exacerbation and remission. • *Very increased risk of cancer. • Lots of complications outside of GI: malabsorption. The entire body is affected. • Lab results will signs of malabsorption. • Number of attacks is correlated with the risk of cancer. • Gemoscan: lab that Dr. Weidenfeld uses to detect food sensitivities. www.gemoscan.com Diet modifications can help patients a great deal. Page 11 ULCERATIVE COLITIS DDX chart with Crohn’s. DIARRHEA Important to be able to DDX source of diarrhea. Chronic laxative users: will present with acute/chronic diarrhea. People don’t always make the connection. Chronic diarrhea can be caused by low-grade pancreatitis with steatorrhea. A lot of people have this condition and are unaware: the only symptom is chronic diarrhea, especially if they eat more fatty foods. Food sensitivities: may present with diarrhea: can’t digest fibre, sugars, lack the enzymes that they require to digest.

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