KURSK STATE

MEDICAL UNIVERSITY
Propaedeutics of Internal Diseases
Department
Professor T.A. Dronova
Lecture

SMALL & LARGE

INTESTINE DISEASES

SMALL-INTESTINAL DISEASES
SYMPTOMS
Small-bowel disease
major clinical manifestations:
Motility disturbances
Abdominal pain & distention
Gastrointestinal bleeding
Malabsorption

SMALL-INTESTINAL DISEASES
SYMPTOMS
Small-bowel disease supposition:
Weight loss
Nutritional deficiencies
Abdominal pain
Diarrhea including steatorrhea

SMALL-INTESTINAL DISEASES
SYMPTOMS
Altered intestinal peristalsis
common manifestation
Decreased motility:
paralytic ileus (metabolic disturbances,
peritonitis)
intestinal obstruction with colicky pain
(tumors, adhesions, intussusceptions)
stasis (permitting bacterial overgrowth)

SMALL-INTESTINAL DISEASES
SYMPTOMS
Diarrhea frequently accompanies

small bowel disease resulting from

direct mucosal involvement by
inflammatory or infiltrative lesions
(sprue, regional enteritis)
Associated malabsorption of fat &
bile salts - important factor in the
pathogenesis of diarrhea

DIARRHOEA
Stool weight increase > 300 g per day

accompanied by increased stool

frequency

Types:
Osmotic diarrhea
Secretory diarrhea
Inflammatory diarrhea
Abdominal motility diarrhea
Antibiotic-associated diarrhea

Osmotic diarrhea
Large quantities of non absorbed hypertonic
substances in gut lumen present
fluid enters bowel due to osmotic pressure:
Purgative intake
Generalized malabsorption
Specific malabsorption (disaccharidase
deficiency)
Osmotic diarrhea stops when patient stops
eating of malabsorptive substances

Secretory diarrhea
Active intestinal secretion of fluid &
electrolytes with decreased absorption:
Enterotoxin (cholera, E.coli)
Bile salts in colon following ileal
resection
Fatty acids in colon following ileal
resection
Food does not affect diarrhea - continues
during fasting

Inflammatory diarrhea
Damage to intestinal mucosal cells loss of fluid & blood:
Dysentery (Shigella)
Ulcerative colitis

Abdominal motility diarrhea

Not true diarrhea - volume &
weight of stool is not increased with
increased frequency of
defecation:
Irritable bowel syndrome
Diabetic neuropathy
Thyrotoxicosis

Antibiotic-associated diarrheaPseudomembranous colitis

After taking antibiotics (particularly
ampicillin, lincomycin & cephalosporin produce pseudomembranous colitis)
Sigmoidoscopy - multiple yellow plaques
& inflammation

SMALL-INTESTINAL DISEASES
SYMPTOMS
Important sign of small-bowel disease -

fat malabsorption
Extensive mucosal damage or
lymphatic obstruction - malabsorption
syndrome or protein-losing
enteropathy

MALABSORPTION
Malabsorption - inadequate transport of one

or more of constituents of normal diet from

intestinal lumen across intestinal epithelium
into portal circulation
CLINICAL FEATURES:
Diarrhea
Abdominal pain
Distension
Weight loss
Nutritional deficiencies

Nutrient absorption
Sites

Duodenum: iron, calcium, magnesium,

folic acid, water soluble vitamins, amino

acids, monosaccharides
Jejunum: fatty acids, amino acids,
monosaccharides, water soluble vitamins
Ileum: monosaccharides, fatty acids,
amino acids, fat soluble vitamins (A, D, E,
K), vitamin B12 & conjugated bile salts

Nutrient absorption
Physiology - 3 phases
Luminal phase: hydrolysis &

solubilization of nutrients
Mucosal phase: further breakdown of
nutrients & transfer into cell
Transport phase: removal of nutrients
into vascular or lymphatic circulation

Intraluminal malabsorption
Disoders

Pancreatic insufficiency:
Chronic pancreatitis
Cystic fibrosis (autosomal disease)
Carcinoma of pancreas
Deficiency of bile acids:
Enterohepatic circulation interruption (resection or
terminal ileum disease)
Small intestine colonization with bacteria which
deconugate bile acids (stagnant loop syndrome)
Uncoordinated gastric emptying:
Gastroenterostomy
Partial gastrectomy

Mucosal phase malabsorption

Disoders
Generalized mucosal abnormalities (histologically

abnormal mucosa):
Coeliac disease (gluten-sensitive enteropathy)
Tuberculosis
Tropical sprue
Lymphoma
Radiation enteritis
Whipples disease (macrophages infiltration)
Malabsorption of specific substances (histologically
normal mucosa):
Lactase deficiency

Transport phase malabsorption

Disoders
Vascular: vasculitis, atherosclerosis
Lymphatic: lymphangiectasia,

infiltrations

Malabsorption Syndrome
Symptoms
GIT system
Genitourinary system
Hematopoetic system
Musculoskeletal system
Nervous system
Skin

MALABSORPTION
Nutritional
deficiencies

Features

Fats

Steatorrhea, frothy
stools, watery diarrhea,
weight loss

Carbohydrates

Flatulent dyspepsia
(borborygmus),
abdominal distension,
flatus, watery diarrhea

MALABSORPTION
Nutritional
Features
deficiencies
Protein Weight loss, muscle wasting,
hypoalbuminuria, oedema,
leuconychia
Folic acid Macrocytic,
megaloblastic anemia,
glossitis, oral mucosa
ulceration in folic acid
deficiency

MALABSORPTION
Nutritional Features
deficiencies
Vitamin B12 Macrocytic, megaloblastic
anemia, glossitis, mental
& neurological
disturbances
Vitamin B
complex

Cheilosis, angular
stomatitis, dermatitis,
polyneuritis

MALABSORPTION
Nutritional
deficiencies

Features

Vitamin C

Bleeding tendency

Vitamin A

Follicular
hyperkeratosis,
xeropthalmia, night
blindness

MALABSORPTION
Nutritional
deficiencies

Features

Vitamin D &
Calcium

Osteomalacia
(rickets), proximal
myopathy,
paraestesia, tetany

Vitamin K

Purpura,
hemorrhages
(bruising & bleeding)

MALABSORPTION
Nutritional
deficiencies

Features

Iron

Hypochromic anemia,
cheilosis, spoon-shaped
nails (koilonychia),
apthous ulcers

Sodium

Muscular weakness,
cramps

MALABSORPTION
Nutritional
deficiencies

Features

Potassium

Flaccidity,
arrhythmias

Magnesium

Muscular weakness,
paraestesia, tetany

Water

Nocturnal diuresis

MALABSORPTION
Nutritional
deficiencies

Features

Zinc

Poor taste, dermatitis,

poor wound healing

Bile salts

Watery diarrhea

SMALL-INTESTINAL DISEASES
SYMPTOMS
Abdominal pain due to small intestinal

disease - usually preumbilical or

supraumbilical & often poorly localized
Intermittent or colicky pain - in
obstruction

SMALL-INTESTINAL DISEASES
SYMPTOMS
Visceral pain - distention or stretching of

intestinal wall or inflammation of overlying parietal

peritoneum
Colicky pain becomes less apparent
progressively dilated intestine with loss of
muscular tone
Steady, aching pain, usually located directly over
inflamed area - acute inflammation of small
intestine with involvement of visceral or parietal
peritoneum (maybe accompanied by guarding &
rebound tenderness - if the parietal peritoneum
involved)

INTESTINAL DISEASES
SYMPTOMS
Gastrointestinal bleeding due to small-bowel

disease may be detected as occult bleeding,

or less commonly, brisk hemorrhage
Appearance of blood in stool depends not
only on bleeding site but also on
hemorrhage rate & rapidity of transit
Small intestinal
bleeding

Bleeding from colon

Black or tarry stool

(melena)

Red blood or clots

LARGE-INTESTINAL DISEASES
SYMPTOMS
Major symptoms - alteration in bowel habit,

rectal bleeding & pain

Alteration in bowel habit - a change from
previous patterns of defecation:
diarrhea - passage of watery or loose stool usually
with increased frequency
constipation - infrequent passage of hard, dry stool
obstipation - absence of spontaneous bowel
movements
Persistent change in bowel habits - important
early symptom of organic colon disease

Difference between small bowel

& large bowel diarrhea
Features

Small bowel
diarrhea

Large bowel
diarrhea

Stool
volume

Large

Small

Stool colour Light

Dark

Difference between small bowel

& large bowel diarrhea
Features

Small bowel
diarrhea

Large bowel
diarrhea

Stool smell

Very foul

Foul

Stool nature Soupy &

greasy

Mucinous &
jelly like

Difference between small bowel

& large bowel diarrhea
Features

Small bowel Large bowel

diarrhea
diarrhea

Stool type Watery

Mucoid

Blood in
stool

Common (usually
fresh blood, if
from caecum
maroon coloured

Rare (if
present
altered)

Difference between small bowel

& large bowel diarrhea
Features

Small bowel
diarrhea

Large bowel
diarrhea

WBCs in
stool

Rare

Common

Abdominal Periumbilical Lower abdomen

pain
region, mid (gripping &
location
abdomen
continuos)
(crampy &
intermittent)

Difference between small bowel

& large bowel diarrhea
Features

Small bowel Large bowel

diarrhea
diarrhea

Tenesmus

Absent

Present

Undigested
material

May be
seen

Invisible

Difference between small bowel

& large bowel diarrhea
Features

Small bowel Large bowel

diarrhea
diarrhea

Steatorrhea

May be
seen

Not seen

Frequency

Less

More

CONSTIPATION
< 3 motions per week or difficult or painful defecation
Causes:
Low fibre diet & lack of exercise & ignoring call to

stool
Drugs (aluminium antacids, psychotropic or opiates)
Irritable bowel syndrome
Colonic carcinoma
Diverticular disease
Anorectal diseases (Crohns disease, hemorrhoids)
Metabolic / endocrine (hypothyroidism,
hypercalcemia)

COLONIC DISEASE
Pain
Localized pain - lower abdominal quadrants
Rectal pain - deep in pelvis
Anal canal pain - accurately localized in perineum
Mechanisms of colonic pain:
distention from gas or fluid causes crampy or colicky
pain from stretching of muscle layers & resulting
contraction or spasm
Pain relieved by passage of flatus or stool
Pain - in colonic wall inflammation or infiltration by tumor
Acute colonic inflammation with involvement of visceral
or parietal peritoneum - sharply localized pain (may be
accompanied by abdominal guarding & rebound
tenderness)

Analysis of severe abdominal pain

Abdominal pain
Site
Radiation of pain

Small-bowel
obstruction
Umbilicus
Nil

Type of pain

Colicky

Severity

Severe

Analysis of severe abdominal pain

Abdominal pain
Onset &
duration

Small-bowel obstruction
Fairy rapid onset & duration:
hours to days

Aggravating
factors

Nil

Relieving
factors

Nil

Analysis of severe abdominal pain

Abdominal
pain

Small-bowel obstruction

Associated
symptoms

Vomiting

On physical Central distinction, increased

examination bowel sounds, finger
examination of rectum: ballooned
& empty rectum (Grekovs sign)
Investigations

X-ray: intestinal fluid level

(Kloibers cups: horizontal fluid
level & gas bubble)

Analysis of severe abdominal pain

Abdominal pain
Site

Complete large-bowel
obstruction
Hypogastrium

Radiation of pain

Flanks

Type of pain

Colicky

Severity

Severe

Analysis of severe abdominal pain

Abdominal pain
Onset &
duration

Complete large-bowel
obstruction
Slow onset, may prolonged
for some days

Aggravating
factors

Nil

Relieving
factors

Nil

Analysis of severe abdominal pain

Abdominal
pain

Complete large-bowel
obstruction

Associated
symptoms

Constipation,
late stage - vomiting

On physical Flank distinction, increased

examination bowel sounds, finger
examination of rectum: ballooned
& empty rectum (Grekovs sign)
Investigations

X-ray: intestinal fluid level

(Kloibers cups: horizontal fluid
level & gas bubble)

COLONIC DISEASE
Rectal bleeding
Diagnostic stool appearance:
Blood coating exterior of formed stool - lesion in

anal canal or rectum

Blood admixed with feces - bleeding source higher
in colon
Brisk hemorrhage from colon or distal small
intestine - passage of fresh blood (hematochezia):
fresh blood & clots - lesion in left colon
dark, maroon-colored blood - bleeding from right
colon

Physical examination in colonic

diseases
Digital rectal examination (perianal, sphinteric &

ampullary lesions, prostatic & uterine

abnormalities, rectal masses & metastatic tumor
in perirectal tissues - Blumers shelf
Fecal material on glove - immediate test with
guaiac-impregnated cards for occult blood

Abnormal stool - objective evidence

of colonic disease
Stool examination by physician - as soon as possible after

defecation for presence of visible blood on surface or within

the specimen, test for occult blood
Microscopic examination of fresh stool - diagnosis of
parasitic diseases (amebic colitis - motile trophozoits in
fresh, warm stool suspension)
Stool suspension stained with a drop of methylene blue for
polymorphonuclear leukocytes indication of presence of
acute inflammatory exudates (ulcerative colitis, amebic
colitis & bacillary dysentery)
Fixed & stained slides of stool for amoebas & other
parasites
Stool culture - for diagnosis of bacillary dysentery
Sudan III stain of stool - screening test for steatorrhea

BARIUM STUDIES
Enteroclysis is a specialized small-bowel barium

study during which barium is infused rapidly via

a nasogastric tube into the jejunum (technique
allows distention of bowel loops & rapid filling
entire small intestine - avoiding problems of
inadequate distention & poor transit sometimes
encountered in routine small-bowel barium
studies)
Enteroclysis - in suspected small-bowel lesions
not visualized by ordinary barium study

BARIUM & ENDOSCOPIC

STUDIES
Barium enema - for identification of colonic

diseases (including diverticulosis & its

complications, motility disturbances,
displacement of colon by extrinsic lesion)
Barium enema - for detection of loss of haustral
markings in chronic ulcerative colitis & for
diagnosis of intestinal fistulas
Fibroptic colonoscopy - for diagnosis of
inflammatory bowel changes or for detection of
colonic neoplasm (with biopsy of suspicious
lesion & removal of polyps)

SIGMOIDOSCOPY &
MESENTERIC ANGIOGRAPHY
Approximately half of all colorectal neoplasm

- in distal 50 cm of bowel (flexible fibroptic

sigmoidoscopes - possible to examine lower
40-60 cm of colon, rigid sigmoidoscope - with
25 cm limit)
Angiography for diagnosis of 2 conditions:
intestinal ischemia & gastrointestinal
hemorrhage

RADIONUCLIED BLEEDING
SCAN
Bleeding from small or large bowel can be localized by

radionuclide scanning of the abdomen after IV injection

of technetium 99m sulphur colloid or autologous red
cell labeled with the same agent
bleeding at rate of 0.1-0.5ml/min or greater - location of
radioactivity in abdomen may indicate bleeding source
radionuclide bleeding scan - non-invasive, particular
advantage in older patients with bleeding from small
bowel or colon
bleeding scan is not recommended in patients with
suspected bleeding from esophagus, stomach or
duodenum (best studied by upper endoscopy)

Ulcerative colitis
Crohns disease
Crohns disease can affect any part of GIT from

mouth to anus (30% -40% in small intestine

alone, 40-50% at both parts, 15-25% colitis
alone, in 90% - terminal ileum)
Crohns disease - transmural process
Ulcerative colitis - mucousal disease that
usually involves rectum & extends proximally to
involve all or part of colon

Digestive system examination

Lips
Labial swelling in Crohns

disease (inflammatory bowel

disease)

Systemic features: arthritis,

iritis, pyoderma
gangrenosum

Disorders causing malabsorption

Coeliac disease
Coeliac disease (gluten-sensitive enteropathy)

immunologically mediated inflammatory

disorder of small intestine in genetically
susceptible individuals
Common in northern Europe
Pathogenesis immunological response to
gluten

Malabsorption Syndrome
Weight loss
Osmotic small intestinal non-inflammatory diarrhea accompanied by

steatorrhea & anemia

Gastrointestinal system:
generalized malnutrition, weight loss (due to malabsorption of fat,
carbohydrates & proteins), diarrhea (due to impaired absorption or
increased of water and electrolytes, unabsorbed bile acids and fatty
acids, excess load of fluid and electrolytes presented to the colon
may exceed its absorptive capacity), flatulence (due to fermentation ),
glossitis, cheilosis, stomatitis ( due to deficiency of B group vitamins
and foliate ) and abdominal pain ( due to distention )
Genitourinary system :
Nocturic (due to delayed absorption of water and hypokalemia )
Hypotension and azotemia (due to fluid and electrolyte depletion )
Sexual disturbance (due to protein depletion & caloric insufficiency
causing secondary hypopituitarism )

 Hematopoietic system:
Anemia ( due to delayed absorption of iron, vitamin B12 and folic

acid )
Hemorrhagic syndrome ( due to Vit K malabsorption and
hypoprothrombinemia )
Musculoskeletal system :
Bone pain ( due to protein depletion and calcium malabsorption
leading to osteoporosis and osteomalacia )
Parasthesias and tetany ( due to hypocalcemia and
hypomagnesemia )
Weakness ( due to anemia and hypokalemia )
Nervous system :
Night blindness and xeropthalmia ( due to Vit A deficiency )
Peripheral neuropathy ( due to Vit B1 and B12 deficiency )

 Skin :
- skin pupura ( due to Vit K deficiency ), dermatitis and follicular

hyperkeratosis ( due to Vit A and zinc deficiency )

- In general, any combination of weight loss, osmotic smallintestinal non-inflammatory diarrhea accompanied by
steatorrhea and anemia ( due to small iron stores, anemia is
usually hypochromic and microcytic )
Laboratory studies :
- The presence of fragments of undigested food steatorrhea,
creatorrhea ( for an adult eating a normal diet with an average
daily fat intake of 100mg, a fecal lost of more than 6mg per
24hrs is abnormal )
Blood test :
- Hb, hematocrit, RBC count, albumin, cholesterol, calcium, iron,
magnesium and potassium levels are diminished and
prothrombin time is prolonged

Extraintestinal findings associated

with small-intestinal diseases
buccal pigmentation or teleangiectasia in co-

existent small-bowel polyposis or intestinal

teleangiectasia with episodes of abdominal pain
or chronic bleeding
evidence of iritis, arthritis, or erythema nodosum
suggestion of inflammatory bowel disease

MALABSORPTION
Laboratory examination
Anemia
Hypoproteinemia
Hypocholesterolemia
Hypoglycemia
Coprological studies: increased undigested food

content & increased excretion enzymic food

decomposition products