GASTROINTESTINAL TRACT

Robbins 8 edition Eric Jake C. Lim, Ph.B, RN, RM, MN, USRN, NMD
th

1.

CONGENITAL ABNORMALITIES a. Atresia, Fistula and Duplications b. Diaphragmatic hernia, Omphalocele, Gastroschisis c. Ectopia d. Meckels diverticulum e. Pyloric Stenosis f. Hirshprung Disease 2. ESOPHAGUS a. Esophageal obstruction i. Achalasia b. Esophagitis i. Laceration \chemical and infectious esophagitis ii. Reflux esophagus iii. Eosinophillic esophagitis c. Barrett esophagus i. Esophageal varices d. Esophageal tumors i. Adenocarcinoma ii. Squamous cell carcinoma iii. Uncommon esophageal tumors _____________ GENERALITIES OF GASTROINTESTINAL DISEASES 1. The following occur in any part of the GI tract a. Atresia b. Fistula c. Duplication 2. When present within esophagus, they are discovered shortly post birth due to: a. Regurgitation during feeding 3. Must be corrected as they are: 4.

3.

Like gastroschisis, is a ventral wall defect Occurs when the closure of the abdominal musculature is incomplete and c. Abdominal hernia herniate into ventral membranous sac Gastroschisis a. Ventral wall defect, just like your omphalocele b. Unlike omphalocele, this involves the whole three layers of the abdominal wall from peritoneum to the skin

a.

b.

ECTOPIA

1. 2. 3.
4. 5.

This is a TRUE diverticulum called MECKELS A blind outpouching of alimentary tract Communicate with eh lumen Included all three layers Most common type of ectopia a. Meckels diverticulum which occurs in the ileum Failure of involution of the vitillene duct Solitary diverticulum is a small outpouching From the antimesenteric side of the bowel

6. 7. 8. 9.

5.

6.

a. Incompatible with life Agenesis a. Uncommon as compared to atresia (which is more common) Atresia a. More common as compared to agenesis b. Occurs commonly at or near fistula connecting the upper and lower esophageal pouches Fistula can lead to a. Pneumonia b. c. d.
Aspiration Suffocation

The true diverticulum includes all these layers a. Mucosa b. Submucosa c. Muscularis propia 10. Disease of 2 a. 2% in population b. Within 2 feet from the ileocecal valve (85cm) c. Approximately 2 inches long d. More greater in males than females e. Symptomatic by age 2 f. Most common at the sigmoid PYLORIC STENOSIS 1. 2. 3. 4. Congenital hypertrophic pyloric stenosis a. 3-4x greater among males than females Also associated with this disorder a. Turner syndrome b. Trisomy 18 Generally appears on the a. 2-3rd week of life Signs and symptoms a. ____________ regurgitation

5.

Severe fluid and electrolyte imbalances e. BRAINSTICKER: PASS 7. Esophageal atresia is associated with a. Congenital heart defects b. Genitourinary malformations c. Neurologic diseases 8. Intestinal atresia a. Less common b. If it does, it is in duodenum, and characterized by lacking of lumen 9. Stenosis a. Incomplete form of atresia with marked reduce caliber due to fibrous thickening 10. Most important form of congenital intestinal atresia a. Imperforate anus 11. Possible causes of stenosis a. Inflammatory scarring b. Irradiation c. Scleroderma d. Caustic injury DIAPHRAGMATIC HERNIA, OMPHALOCELE, AND GASTROSCHISIS 1. Diaphragmatic Hernia a. Occur with incomplete formation of diaphragm b. Allows viscera to herniated into thoracic cavity c. Incompatible with life after birth Omphalocele

6. 7.

8.

b. Persistent, projective, nonbilous vomitus PE reveals a. Hyperperistalsis b. Firm, ovoid, abdominal mass Surgical splitting of muscularis a. Myotomy is curative With the adults (Pathology) a. This is the result of i. Antral gastritis or ii. Peptic ulcers close to pylorus Due to fibrosis or malignant infiltration

HIRSCHPRUNG

1. 2.
3.

Approximately 1 of 5000 live births 10% of cases occur with down syndrome and those with serious neurologic abnormalities Other names a. Congenital aganglionic megacolon b. Distal intestinal segment i. Meisners and ii. Auerbach Simple Mendelian inheritance is not involved in most cases. What accounts for the majority of familial cases up to 15% is a. Heterozygous loss-of-function, mutation in the receptor tyrosine kinase RET Gender preference a. Women > Males Diagnosis a. Documentation of the absence of ganglion cells within the affected segment

4.
5.

6. 7.

2.

Gastrointestinal Tract, Robins 8th Edition. Encoded by EJCL for GenPath Laboratory page 1 of 3

Immunochemical stains i. Acetylcholinesterase 8. Rupture most frequently happens near the a. Cecum 9. Signs and Symptoms a. Neonatally present b. Failure to pass meconium immediately post natal period c. Occasional passage of stool 10. Acquired Megalocolon a. Chagas disease b. Obstruction by i. Neoplasm ii. Inflammatory disease/structure iii. Toxic megalocolon complicating ulcerative colitis ESOPHAGITIS

b.

2.

In contrast to those located at the squamocolumnar junction of LES which is designated as a. B-rings b. May have gastric cardia type mucosa undersurface

ACHALASIA 1. Increase tone of LES Results from impaired smooth muscle relaxation (important cause of obstruction) 3. TRIAD of Achalasia a. Incomplete relaxation of LES

2.

1. 2.

Develops from cranial portion of the foregut Recognizable on the 3rd week

4.

ESOPHAGEAL OBSTRUCTION 1. 2. 3. 4. Outer longitudinal layer contracts before the inner circular (ICOL-remember?) Term for the lack of coordination syndrome a. Nutcracker Esophagus Other motor disorders of esophagus a. Diffuse esophageal spasm (resulting in obstruction) Because of so much stress due to diffuse esophageal spasm, it results to a. Diverticulae form ZENKER DIVERTICULUM a. AKA Pharyngoesophageal diverticulum b. Located immediately above UES c. Opposite to that of Epiphrenic which is above LES TRACTION DIVERTICULUM a. Occurs near midpoint of esophagus EPIPHRENIC DIVERTICULUM Immediately above LES Opposite to that of Zenker which is above UES ESOPHAGEAL STENOSIS a. Can also impede passage of food b. Due to fibrous thickening of mucosa b.

5.

6.

5.

7.

Aperistalsis of esophagus Primary Achalasia a. Failure of the distal esophageal inhibitting neurons b. Idiopathic Secondary Achalasia a. Chagas disease (due to Trypanosoma Cruzi) which affects the following i. Duodenal ii. Colonic iii. Ureteric ACHALASIA-LIKE Disease a. Diabetic autonomic neuropathy b. Infiltrative disorder like i. Malignancy ii. Amyloidosis iii. Sarcoidosis TREATMENT for Primary and Secondary a. Myotomy and b. Pneumatic balloon dilation

b. c.

Increase tone of LES

6. 7.

ESOPHAGITIS, Type of 1. 2. 3. 4. Laceration Chemical and infectious Reflux esophagitis Eosinophilic esophagitis

a.

8.

LACERATIONS 1. Longitudinal tears called a. Mallory-Weis Tears i. Severe retching ii. Vomiting secondary to alcohol intoxication 2. Type of laceration (Mallory-Weis) a. Roughly, linear lacerations are i. Longitudinally oriented and large in length 3. Maybe located at a. Proximal gastric mucosa 4. Up to 10% causes a. GI Bleeding 5. DO NOT usually require a. Surgical Intervention 6. In contrast, BOERHAAVE SYDROME a. Distal esophageal rupture b. Mediastinitis c. Rare to occur with catastrophic event 7. PILL-INDUCED ESOPHAGITIS a. When medicine-pill lodged and dissolve in the esophagus 8. IATROGENIC causes a. Cytotoxic chemotherapy b. Radiation therapy c. G-vs-H disease 9. Common esophageal infection a. HSV b. CMV c. Fungi i. Candidiasis ii. Mucormycosis and aspergillosis 10. Desquamative diseases a. Bullous pemphigoid b. Epidermis bullosa c. Rarely, Crohns disease REFLUX ESOPHAGITIS

Associated with atrophy of muscularis propia 9. Other causes a. Inflammation and scarring b. Chronic GER c. Irradiation d. Caustic injury 10. ESOPHAGEAL MUCOSAL WEBS a. Uncommon ledge-like protrusion of mucosa b. Unknown pathogenesis c. > woman over 40 d. Associated with GERD, chronic G-vs.-H, or blistering disease e. UPPER ESOPHAGEAL WEBS i. Associated with iron deficiency anemia f. Site where esophageal webs are more common i. Upper esophagus g. PATTERSON-BROWN-KELLY or Plummer Vinson TRIAD i. IDA ii. Glossitis iii. Cheilosis h. Main symptom i. dysphagia i. ESOPHAGEAL RINGS aka SCHATZKI-Ring i. Similar to webs ii. But are circumferential and thicker iii. When present above gastroesophageal junction on the distal past they are called a RING 1. Covered by squamous mucous

c.

Gastrointestinal Tract, Robins 8th Edition. Encoded by EJCL for GenPath Laboratory page 2 of 3

1. 2.

3.

4. 5.

6.

7. 8.

Stratified squamous epithelium is resistant to abrasion Submucousal glands, abundant in the proximal and distal esophagus serves as protection by secreting a. Mucin and b. Bicarbonate HC03Very important a. Constant LES prevents reflux of acid gastric contents What is so central to the development of GERD a. Reflux of gastric juices Conditions that decreases LES a. Increase abdominal pressure b. Alcohol, tobacco c. Obesity d. CNS depressants e. Pregnancy f. Hiatal hernia g. Delayed gastric emptying Most common SSx a. Dysphagia b. Heartburn c. Less frequently i. Regurgitation of sour taste Common among adults a. Over 40 years old b. Also occurs in infants and children Treatment a. Proton pump inhibitors H2 blockers Complications a. Esophageal ulceration b. Hematemesis c. Melena d. Stricture development e. Barrett esophagus

i. Low grade or ii. High grade 11. Clinical feature a. Can be identified only with (usually prompted by frequent GERD) i. Endoscopy ii. Biopsy 12. Treatment Options a. Surgical resection or esophagectomy b. Photodynamic therapy i. Laser ablation c. Endoscopic mucosectomy ESOPHAGEAL VARICES 1. Circulatory pattern is responsible for 1st pass effect

2.

3. 4.

Disease that impedes this flow causes a. Portal vein hypertension b. This leads to varices formation c. Which is secondary to collateral channel development d. 90% of antibiotic clients Hepatic Schistosomiasis a. Second leading cause of esophageal varices Treatment a. Sclerotherapy by endoscopic injection of thrombotic agent b. Endoscopic balloon tamponade c. Endoscopic rubber band ligation

b.

9.

ESOPHAGEAL TUMORS, subtypes 1. Adenocarcinoma 2. Squamous cell carcinoma 3. Uncommon esophageal tumors ADENOCARCINOMA 1. Typically arise in a background of Barretts and longstanding GERD 2. Risk factors a. Tobacco b. Obesity c. Prior radiation therapy 3. Reduced by a. Fresh fruits b. Vegetables 4. Other causes a. Helicobacter pylori i. Gastric atrophy ii. Reducing acid reflux 5. Gender a. 7x in males than females 6. Molecular basis a. Stepwise acquisition of i. Genetic ii. Epigenetic changes 7. Chromosomal abnormalities a. Increase p53 at the early stage of Barrett Esophagus SQUAMOUS CELL CARCINOMA 1. 4x greater in females than males 2. Risk factors a. Alcohol b. Tobacco c. Caustic d. Achalasia e. Poverty f. Plummer-Vinson g. Hot beverages h. 6x common among African-Americans than Caucasians 3. Implicated agent a. HPV 4. Loss of a. Tumor suppressor genes i. P53 ii. P16/INK4a 5. Squamous versus Adenocarcinoma a. Half of squamous occurs in the middle third of esophagus b. Squamous begins as tumor in situ c. Early lesion presents i. Small ii. Gray-white iii. Plaque-like formation d. Most squamous are moderately to well differentiated e. Less common histologic variant i. Verrucous type

EOSINOPHILIC ESOPHAGUS 1. SSx Food impaction Dysphagia in adult Feeding intolerance or GERD like among children The abundance of eosin can help in the diagnosis of Eosinophilic Esophagus versus GERD or Crohns. Majority of individuals with eosinophilic esophagitis are atopic and many have atopic dermatitis, allergic rhinitis, asthma, or modest peripheral eosinophilia. Treatments a. Dietary restriction such as i. Cows milk ii. Soy products iii. Topical or systemic corticosteroids a. b. c.

2. 3.

4.

BARRETS ESOPHAGITIS 1. Complication of a. GERD 2. Characterized by a. Intestinal metaplasia within the esophageal squamous mucosa (when this develops columnar which isnt native to this area) 3. White > Blacks 4. > 40 years old 5. More similar to that of Adenocarcinoma than the normal esophageal epithelium 6. What is considered as pre-invasive lesion a. Dysplasia 7. Although they resemble more like that of Adenocarcinoma, a. Most clients with BARRETTs dont develop esophageal tumors 8. Morphology a. Several tongues or patches of red, velvety mucosa b. Metaplastic mucosa alternates with residual smooth, pale squamous 9. TWO subtypes of Barretts a. Long (>3 cm) b. Short (<3 cm) 10. Diagnosis (histopath) a. Goblet cells (with distinct mucous vacuoles) b. Intestinal metaplasia c. When DYSPLASIA is present this is diagnosed as either

Gastrointestinal Tract, Robins 8th Edition. Encoded by EJCL for GenPath Laboratory page 3 of 3

6.

Clinical features a. Insidious and produces dysphagia, odynophagia, and obstruction

UNKNOWN ESOPHAGEAL TUMOR 1. Adenocarcinoma 2. Undifferentiated carcinoma 3. Carcinoid tumor 4. Melanoma 5. Lymphoma 6. Sarcoma

Gastrointestinal Tract, Robins 8th Edition. Encoded by EJCL for GenPath Laboratory page 4 of 3