GASTROINTESTINAL

SYSTEM
TOPIC OUTLINE
I. Gastrointestinal tract
a. Anatomy
b. Physiology
c. Digestive process
d. Neural control
II. Signs and Symptoms of Gastrointestinal
disorders
III. Gastrointestinal disorders
IV. Pain patterns
GASTROINTESTINAL TRACT

Upper GI
• mouth, esophagus, stomach

Middle GI
• small intestine (duodenum, jejunum and ileum)

Lower GI
• large intestine (cecum, colon, rectum)

Accessory organs
• salivary glands, liver, gall bladder, pancreas, spleen
DIGESTION PROCESS
a. Mastication
b. Deglutition
DIGESTION PROCESS
a. Mastication

 Muscles of Mastication:
 Temporalis

 Medial Pterygoid
 Masseter

 Lateral Pterygoid

 Chewing reflex
DIGESTION PROCESS
b. Deglutition

 Stages of Swallowing:

Pharyngeal
• initiates • involuntary
swallowing • involuntary (pharynx to
process (pharynx to stomach)
esophagus)
Voluntary Esophageal
STOMACH
 Motor functions:

1. Storage of food
2. Mixing of food with

gastric secretions to form

chyme
3. Slow emptying of the

chyme to the small

intestine
STOMACH

 Gastric juices:
 Cholecystokinin
 Gastrin
 HCl
 Pepsin
 Intrinsic
factor
 Pancreatic enzymes
SMALL INTESTINE
 Movements of small
intestine

1. Mixing contractions –
Segmentation

2. Propulsive movements
LARGE INTESTINE
Principal functions:

1. Absorption of water
and electrolytes from
chyme to form solid
feces

2. Storage of fecal
matter
ACCESSORY ORGANS
a. Salivary glands
b. Liver
c. Gallbladder
d. Pancreas
e. Spleen
SALIVARY GLANDS
 Functions of Saliva:
1. Lubrication
2. Bactericidial
property

 Major types of
secretions:
1. Ptyalin
2. Mucin
LIVER
 Bile: mixture of water, bile salts, cholesterol,
and the pigment bilirubin

 Emulsification of fats
LIVER
GALLBLADDER
PANCREAS
SPLEEN
NEURAL CONTROL
 Enteric Nervous System:
 controlling gastrointestinal movements and secretion

 Autonomic Nervous System (ANS)

 Sympathetic and parasympathetic plexuses

 Vasovagal reflex
 Controls secretions and motility of the GI tract
NEURAL CONTROL

 Reflexes:
 Gastrocolic reflex:

 Enterogastric reflex:

 Colonoileal reflex:
SIGNS AND SYMPTOMS
ABDOMINAL PAIN
1. EPIGASTRIC REGION
 T3-T5 sympathetic nerves
 ORGANS:
 Heart
 Esophagus
 Stomach`
 Duodenum
 Gallbladder
 Liver
ABDOMINAL PAIN
2. PERIUMBILICAL REGION
 T9-T11
 ORGANS:
 Small intestine
 Pancreas
 Appendix
ABDOMINAL PAIN
3. HYPOGASTRIUM
 T10 – L2
 ORGANS
 Large intestine
ABDOMINAL PAIN
REFERRED PAIN
ORGANS REFERRED TO
Esophagus Mid-back
Liver, diaphragm,
Shoulder
pericardium
Gallbladder, stomach, Mid-back and scapular
pancreas, small intestine region

Colon, appendix, pelvic

Pelvis, flank, low back or
viscera, sigmoid, rectum,
sacrum
ureters and testes
NAUSEA AND VOMITING

 Can be triggered by food, drug, shock,

inflammation of abdominal organs, distention,
irritation of the GI tract, motion sickness

 Complications:
 fluid
and electrolyte imbalance
 pulmonary aspiration

 GI damage
DYSPHAGIA
 choking, coughing, or abnormal sensations of food
sticking in the back of the throat or esophagus

 Causes:
 GI Causes:
 Non-GI Related:

 Achalasia: condition in which the LES fails to relax

and food is trapped in the esophagus
EPIGASTRIC PAIN WITH RADIATION

 Heartburn
 Caused by reflux gastric contents into the
esophagus
 Symptoms:
 Bitter or sour taste in the back of the throat
 Abdominal bloating
 General abdominal discomfort

 Aggravated by: certain foods, increased

abdominal pressure, positions/movements
ANOREXIA
 Associated with anxiety, fear, and depression

 Anorexia nervosa: prolonged loss of appetite

and inability to eat

 S/Sx: Amenorrhea, Broken blood vessels in the

eyes, Tooth marks/scratches in the back of
hands
DIARRHEA
 Acute: enteric infection
 Chronic: neoplastic or IBD
 Drug-Induced Diarrhea: Clostridium Difficile

 Complications:
 Electrolyte imbalance
 Dehydration & thirst
 Dizziness
 Weight loss

 Precautions:
 Handwashing, gloves, extremely careful cleaning of bathroom
and linen
CONSTIPATION
 Factors that can trigger constipation:
 Diet lacking in bulk and fiber, stress, inadequate fluid
consumption, sedentary lifestyle, increasing age and
drugs, muscle guarding and splinting

 Obstipation
 Intractable constipation with resulting fecal
impaction, retention of hard dry stools in the rectum
and colon

 Can cause partial or complete bowel obstruction

GASTROINTESTINAL BLEEDING
 Coffee ground emesis

 Melena

 Bloody diarrhea

 Bright red blood stool

 Reddish/Mahogany-colored stool

 Light/gray colored stool

OBTURATOR OR PSOAS ABSCESS
 Results from direct extension of intraabdominal
infections

 M/C cause: Staphylococcus Aureus

 Clinical manifestations:
 Fever,night sweats, lower abdominal, pelvic and
back pain or pain referred to the hip, medial thigh
or groin, or knee, antalgic gait
OBTURATOR OR PSOAS ABSCESS
 Screening Tests:
 Heel tap

 Hop test

 Iliopsoas muscle test

OBTURATOR OR PSOAS ABSCESS
 Palpate for the iliopsoas muscle

 Obturator muscle test

 Psoas abcess vs femoral hernia

GASTROINTESTINAL
SYSTEM DISORDERS
GASTROESOPHAGEAL REFLUX
DISEASE
 Reflux or backward
movement of gastric
contents of the stomach
into the esophagus,
producing heartburn

 Failure of the LES

 Heartburn occurs 30-60

minutes after eating
GASTROESOPHAGEAL REFLUX
DISEASE
 TYPICAL SYMPTOMS  ATYPICAL SYMPTOMS
 Heart burn  Chest pain
 Regurgitation with unrelated to activity
bitter taste in mouth  Feeling of lump in
 Belching the throat
 Dysphagia
 Odynophagia
 hoarseness
 Sore throat,
laryngitis
 Weight loss, Anemia
 Asthma
GASTROESOPHAGEAL REFLUX
DISEASE: MEDS
• Prilosec (omeprazole), Prevacid
PPI (lansoprazole), Nexium
(esomeprazole)

H2 • Tagamet (cimetidine), Zantac

BLOCKERS (ranitidine), Pepcid (famotidine)

ANTACIDS • Maalox, Mylanta, Tums, Rholaids

GASTROESOPHAGEAL REFLUX
DISEASE: PT MX
 Schedule of therapy:

 Avoid Valsalva maneuver

 Lifestyle Modification:
 Avoidance of large meals and certain foods
 Do not eat 3 hours before bedtime

 Sleeping position:
HIATAL HERNIA
 LES becomes enlarged, allowing the stomach to
pass through the diaphragm into the thoracic cavity

 May be congenital or acquired

 Caused by increase intra-abdominal pressure such

as lifting, bending over, ascites
HIATAL HERNIA
SLIDING vs. ROLLING
GASTRITIS
 Inflammation of the
stomach mucosa

 Acute or Chronic

 Symptoms:
 Stomach pain
 Bleeding
 Nausea
 Vomiting
GASTRITIS

 Management:
 Dietary modification
 PPIs

 H2 blockers
 Antacids
PEPTIC ULCER
 Loss of tissue lining in the lower esophagus,
stomach and duodenum
PEPTIC ULCER
GASTRIC DU
CAUSE NSAID H. PYLORI

1-2 inches to the right,

2 inches above and
PAIN LOCATION halfway of xiphoid
right of umbilicus
and umbilicus

Empty stomach,
Aggravated by food
PAIN between meals,
intake
early morning
VOMITUS Bright red, coffee ground emesis
STOOL Dark tarry stool
PEPTIC ULCER
 Signs and symptoms:
 Heartburn
 Night pain, ® sh pain
 Lightheadedness
 Nausea, vomiting (coffee ground)
 Anorexia, weight loss
 Bloody stools
 Black tarry stools
PEPTIC ULCER: MX
 Treating H.Pylori : Antibiotics

 Acid-supressing drugs: PPIs, H2 blockers, antacids

 Surgery : indicated for perforation, uncontrolled

bleeding

 Dietary modification
MALABSORPTION SYNDROME
 Problems in intestinal absorption of nutrients

 Deficient enzymes (pancreatic lipase), bile salts

 S/Sx:
 Anorexia
 Weight loss
 Abdominal bloating
 Pain and cramps
 Indigestion, diarrhea
 Steatorrhea (fats in feces)
MALABSORPTION SYNDROME

DEFICIENCY EFFECT

Iron Iron-deficiency anemia

Vitamin K Easy bruising and bleeding

Protein, iron, folic acid, vitamin B Muscle weakness and fatigue

Bone loss, pain, predisposition
Vitamin D
to develop fractures
Neuropathy (tetany,
Calcium, vitamin B and D, paresthesia, numbness,
magnesium, potassium tingling), mm spasm
INFLAMMATORY BOWEL DISEASE
 Inflammation of the bowel and characterized
by remissions and exacerbations

 Chronic inflammatory intestinal disorders:

 Chron’s Disease
 Ulcerative colitis
INFLAMMATORY BOWEL DISEASE
Crohn’s Disease Ulcerative Colitis
Mouth to the anus Inner lining of the large
intestine (colon) and rectum
(R) lower quadrant pain (L) colon is more involved

Pain relief after passing >20 stools a day

stool or gas Bloody diarrhea
Watery diarrhea
INFLAMMATORY BOWEL DISEASE
 SIGNS AND SYMPTOMS:
 Diarrhea, constipation
 Fever, Night sweats
 Abdominal pain
 Rectal bleeding
 Decreased appetite, nausea, weight loss
 Skin lesions, uveitis, migratory arthralgias,
hip pain (iliopsoas abscess)
IRRITABLE BOWEL SYNDROME
 “common cold of the stomach”

 Functional disorder of motility in the small and

large intestines

 Other descriptive names:

 Spastic colon, nervous/irritable colon, nervous
indigestion, spastic colitis, intestinal neuroses,
laxative or cathartic colitis
IRRITABLE BOWEL SYNDROME
 SIGNS AND SYMPTOMS
 Painful abdominal cramps – (L) Lower Quadrant
 Altered bowel habits (Constipation/Diarrhea)
 Nausea and vomiting
 Anorexia
 Flatulence
 Foul breath

 Intervention
 Stressreduction
 Regular physical activity
DIVERTICULAR DISEASE
 Diverticulosis
 pouch-like herniations of the colon
 Diverticulitis
 Inflammation and infection of one or more diverticula
DIVERTICULAR DISEASE
 S/Sx:
 (L) lower abdominal/pelvic pain and
tenderness
 Loss of appetite, nausea, abdominal bloating
 Bloody stools
 Low grade fever
PERITONITIS
 Inflammation of the peritoneum

 D/t bacterial invasion and infection

 E. coli, streptococci, etc.

 D/t: penetrating wounds, surgery, perforated peptic

ulcer, ruptured appendix, gangrenous bowel, pelvic
inflammatory disease
PERITONITIS
S/Sx:
 severe abdominal pain, rigidity from reflex guarding,
rebound tenderness, decreased or absent bowel
sounds, nausea and vomiting, tachycardia

 Elevated WBC count, fever, electrolyte imbalance,

hypotension
HEMORRHOIDS
 Varicosities in the lower rectum and anus

 Caused by congestion of the veins in the

hemorrhoidal plexus.

 s/sx:
 Local irritation, pain, rectal itching
HEMORRHOIDS
 Management:
 Topical medications
 Dietary changes

 Sitz baths

 Local hot or cold compress

 Ligation and surgical excision

APPENDICITIS
 Inflammation of the vermiform appendix

 Immediate medical attention is required

APPENDICITIS
 S/Sx:
 Pain is abrupt in onset, localized
epigastric/periumbilical area
 (R) lower quadrant / flank pain

 (R) thigh, groin, or testicular pain

 Abdominal involuntary muscular guarding and rigidity

 Blumberg Sign - rebound tenderness

 McBurney’s point- point tenderness

 Nausea and Vomiting

 Low grade fever

APPENDICITIS
MCBURNEY’S POINT
PRANCREATITIS
 Inflammation of the pancreas secondary to
autodigestion of its own enzymes

 Causes:
 Unknown
 Chronic alcoholism
 Diuretics
 viral infection
PRANCREATITIS
 ACUTE PANCREATITIS
 Epigastric pain radiating to the back
 Nausea, vomiting, diarrhea
 Abdominal distention and pain
 Fever and sweating
 Malaise, Weakness
 Bluish discoloration of abdomen or flanks (severe
hemorrhagic acute pancreatitis)
PRANCREATITIS
PRANCREATITIS
 CHRONIC PANCREATITIS
• Epigastric pain radiating to the back

• Upper (L) lumbar region pain

• Nausea and vomiting

• Constipation

• Flatulence

• Weight loss
HEPATIC AND BILIARY DISEASE
 LIVER  GALLBLADDER
 Jaundice
 Bruising
 Spider Angioma
 Palmar erythema
 Nails of Terry
 Dark Urine
 Light-colored stool
 Ascites
 Hyperreflexia
 Asterixes
 (R) UQ pain
 Jaundice
 Low grade fever
 Belching
 Flatulence
 Fatty food intolerance
 Mid-epigastric pain
 (R) upper abdominal
pain
 Ant. Rib pain (tip of 10th
rib; 11 and 12th rib
HEPATIC DISEASE
CIRRHOSIS
 Chronic hepatic disease

 Destruction of liver cells

 Replacement of connective tissue by fibrous bands

 Portal hypertension, ascites, esophageal varices

CHOLELITHIASIS
• Gallstones
• Etiology
• supersaturation of the bile with cholesterol

• Crystal formation from bilirubin salts

• Symptom
• often asymptomatic

• Sometimes (R) upper quadrant pain

BILIARY COLIC
 Stone gets lodged in the neck of the gallbladder

 Classic symptom:
• (R) upper quadrant pain that comes and goes in waves
• Pain peak and fades away
CHOLECYSTITIS
 Blockage of gallstones in the CYSTIC DUCT leading to
infection and inflammation of the gallbladder

 “HOT RIB”
 Tenderness over the gallbladder
 Steady and severe pain
CHOLANGITIS
 Gallstones lodged further down in the system in the
COMMON BILE DUCT

 (+) JAUNDICE

 Can lead to infection and travel up to liver (Life

threatening)
PAIN PATTERNS
PAIN PATTERN: ESOPHAGUS
PAIN PATTERN: STOMACH AND
DUODENUM
PAIN PATTERN: SMALL INTESTINE
PAIN PATTERN: LARGE INTESTINE
PAIN PATTERN: PANCREAS
PAIN PATTERN: APPENDIX
PAIN PATTERN: LIVER AND
GALLBLADDDER
Thank you for listening!