Ulceroinflammatory Disorders of the GIT

Dr. Mehzabin Ahmed

TOPICS Common symptoms & terminology Disorders of :

Mouth: Ulcers, Premalignant lesions Pharynx: Infections, Tumors Salivary gland: Inflammations, Tumors Esophagus: Hiatus hernias, Barrett esophagus Stomach: Peptic ulcers Intestines: Inflammatory bowel disease (Crohn

disease & ulcerative colitis) and Malabsorption syndromes

The gastrointestinal tract extends from the mouth to the

anus and includes the oral cavity and salivary glands,

pharynx, oesophagus, stomach, small and the large

intestines.

The main function of the GIT is digestion, absorption

and assimilation of the food consumed.

1. Dysphagia: Difficulty in swallowing.

Causes : Acute infections of the pharynx or tonsils, or Obstruction by foreign bodies or tumors (in the oesophagus or outside

it producing compression) or Impaired neuromuscular function (as in achalasia cardia or multiple

sclerosis)

2. Leukoplakia: is a term used to describe the white patches of keratosis (increased keratinization) resulting due a chronic irritation. It is characterized by Hyperkeratinization and hyperplasia of the squamous epithelium Dysplasia in some cases and in these situations it is premalignant.

3. Heart burn: burning pain in the epigastric region due to: Irritation of the oesophageal or the gastric mucosa, usually with

inflammation and ulceration (peptic ulcers, reflux esophagitis). 

4.    Abdominal pain: it can originate in the a) Viscera: due to spasm or colic of the muscular layer of the gut b) Peritoneum: due to irritation or inflammation5.    Blood loss: it may be asa)   Hematemesis: Vomiting of blood- usually due to an upper GI

bleeding, due to: Oesophagus: ruptured blood vessels (oesophageal varices) r Stomach: due to

an erosion by an ulcer Mallory Weis syndrome (oesophageal mucosal tears in chronic

alcoholic occurring due to retching and vomiting b)   Melena: passage of altered blood in the stools.

the blood lost may originate from - Upper GI:. It occurs in ulcers and tumors of the stomach and

duodenum- Lower GI: the blood in the stools appears fresh and red. It occurs

in ruptures anal fissures, hemorrhoids (piles), or ulcers and tumors of the colorectum.

6. Weight loss: it may be due

· Impaired food intake: as in eating disorders

·  Malabsorption syndromes

·  Increased catabolism a/w a malignant tumor.

7. Anaemia: it may be due to blood loss or due to impaired absorption of iron, folic acid or B12 (either due to a mucosal abnormality eg.

pernicious anaemia or to a defect in the transport proteins)

8. Diarrhoea: Causes: an impaired absorption (usually due to an infective cause as in cholera, shigellosis and are called infective diarrhoeas) or excessive secretion of fluid (osmotic diarrhoea- as in lactose intolerance)

9. Steatorrhoea: due to impaired absorption of fat either because of reduced lipase secretion or reduced absorption area or due to lymphatic obstruction.

Mouth 

Ulcers: The oral mucosa is commonly affected by ulcers. These may be infectious (herpes virus, candida albicans) or non infectious (aphthous ulcers- due to an

immunological imbalance, or associated with Crohn’s disease- usually self limited).

Leukoplakia: premalignant lesion resulting from a chronic irritation- if untreated leads to squamous cell carcinoma.

Leukoplakia- hyperkeratosis

Aphthous ulcers

PHARYNX

Most infections of the pharynx are due to a viral infection like influenza, measles, rhinovirus, infectious

mononucleosis. Bacterial infections due to streptococcus

important because of their complications, like rheumatic fever and its complications, glomerulonephritis, and vascultis.

Tumors: Ebstein Barr virus is implicated in the development of Nasopharyngeal carcinoma.

Salivary glands Inflammations of the salivary glands is called sialedinitis.

It may be due to bacterial/ viral infections or autoimmune reaction.

Bacterial infections can act as a nidus for stone formation, resulting in duct obstruction.

Tumors: the most common tumor of the salivary gland is the mixed

tumor or the pleomorphic adenoma. The adenoid cystic carcinoma is a malignant tumor of the

salivary glands that involves the parotid gland, and commonly extends and infiltrates into the facial nerve leading to paralysis.

Esophagus Congenital conditions like

Atresia (failure to canalize/ absence of the lumen) Diverticula (formation of outpouchings in the wall) Tracheoesophageal fistula (fistula-abnormal connections between two hollow organs) may be

seen. Hiatus hernia is the presence of a part of the stomach above the diaphragmatic orifice. It may be

due to a congenital shortening of the esophagus, or in aged patients due to increased abdominal pressure coupled with a decreased diaphragmatic

muscle tone. Achalasia is a condition when the contractility of the lower esophagus is lost and failure of

relaxation of the sphincter. It may be due to destruction or degeneration of the myentric plexus as in neurotropic infection like Chaga’s

disease or due a congenital absence of the ganglion cells of the myentric plexus.

Esophageal atresia

A,B-Tracheoesophageal fistulas

C- Esophagela atresia with fistula

A B C

Oesophageal varices are dilated veins of the lower esophagus, which serve as shunts when portal venous flow through the liver is impaired. It is a cause for massive hematemesis. Other sites of varices are around the anus and the umbilicus.

Reflux esophagitis is a chronic inflammation in the esophagus occurring as a result of the regurgitation of the acidic gastric contents. It produces heartburn

Barrett’s esophagus is a metaplastic change in the mucosal lining of the lower esophagus, from stratified nonkeratinized epithelium to columnar epithelium, occurring as a result of longstanding reflux. Its significance lies in the fact that it is premalignant.

Tumors involving the oesophagus could be benign like the leiomyoma (smooth muscle tumor) or carcinoma (squamous cell carcinoma or the adenocarcinoma).

StomachCongenital pyloric stenosis is the hypertrophy of the circular

muscle coat of the pyloric sphincter leading to an outflow obstruction.

Acute gastritis: It is the acute inflammation of the stomach in response to an

irritant chemical like drugs or alcohol. The principal drugs implicated are the nonsteroidal anti-

inflammatory drugs (NSAIDs), notably aspirin. These agents result in exfoliation of the surface epithelial cells

and decrease the secretion of the mucus. Inhibit the prostaglandin synthesis.

Other causes include excessive alcohol ingestion, heavy smoking, cancer chemotherapy, severe stress as in burns/trauma/surgery (Curling’s ulcers), irradiation, ingestion of acids/ alkali, systemic infection and ischemia and shock.

Depending on the severity there may be lesions ranging from vasodilatation and edema to erosions and hemorrhage. Erosion is a partial loss of mucosa whereas an

ulcer is a full thickness loss. Erosions in acute gastritis are usually multiple and frequently bleed causing hemorrhage.

Chronic gastritis is frequently due to Helicobacter pylori infection, or may be autoimmune (associated with vitamin B12 deficiency resulting in megaloblastic anemia- pernicious anemia) or chemical injury due to NSAIDs, chronic bile reflux or alcohol, radiation, post surgery, obstruction, and chronic granulomatous conditions like Crohn’s disease.

Peptic ulceration Ulcers are a breach in the continuity of the mucosal epithelial lining of the

alimentary tract extending through the muscularis mucosa into the submucosa or deeper, arising as a result of the acid and pepsin attacks on the mucosa.

Normally these attacks are counteracted by the defense mechanism like the mucus- bicarbonate barrier, increased mucosal blood flow, increased regenerative capacity of the epithelium and prostaglandin secretion by the epithelium.

Ulcers result when the mucosal defenses are weakened or when the damaging forces are increased.

This occurs in:

1. Helicobacter pylori infection-

1. releases enzymes (digests the mucosal lining) and

2. lipopolysaccharides (attract the inflammatory cells which release digestive enzymes) and

3. a platelet activating factor that promotes the thrombotic occlusion of the surface capillaries (promotes ischemic damage)

2. Chronic use of NSAIDs- these suppress the prostaglandin secretion

3. Increased gastric acidity as in gastrinomas (increased gastrin secretion)- Zollinger Ellison syndrome.

4. Chronic smoking, alcohol ingestion, corticosteroid administration are other causes.

Major sites include first part of the duodenum, junction of the

antrum and the body of the stomach, distal oesophagus, at the

gastro enterostomy stoma (post partial gastrectomy patients) and

in Meckles diverticula (sac like out pouching from the intestinal

wall)

Clinically the patient presents with a burning pain, which is

worse at night and 1-3 hours after meals, nausea, vomiting,

bloating, belching, and weight loss.

Complications of the ulcers include hemorrhage, anemia,

extension and perforation of the ulcers, and obstruction due to

healing by fibrosis.

IntestinesCongenital abnormalities include atresia, stenosis, diverticula and

Hirschsprung’s disease (absence of ganglion cells in the large intestine (rectum and sigmoid colon).

Malabsorption: The sub optimal absorption of nutrients (carbohydrates, proteins, fats, vitamins, electrolytes and minerals) and water. It is classified as due to

1. Defective digestion: due to deficiency of enzymes2. Mucosal cell abnormalities: results in defective terminal

digestion and/or defective transport of the nutrients3. Reduced small intestinal surface area: Celiac sprue or

Iatrogenic: post surgical resection 4. Lymphatic obstruction: due to lymphoma or tuberculosis:

resulting in deficient fat absorbtion5. Infections: tropical sprue, parasites, and Whipple’s disease.

The clinical consequences of malabsorption syndromes

1. Alimentary tract: diarrhea, pain, weight loss, passage of bulky,

greasy stools

2. Hematopoietic system: causes anemia, bleeding

3. Musculoskeletal system: osteopenia and tetany (hypocalcemia)

4. Endocrines: amenorrhea, impotence, infertility and

hyperparathyroidism

5. Skin: purpura, petechia, edema, dermatitis

6. Nervous system: peripheral neuropathy

Idiopathic inflammatory bowel disease

It includes Crohn’s disease and ulcerative colitis

Crohn’s disease is a granulomatous disease affecting any portion of the gut

but most often the small intestine and colon.

Ulcerative colitis is a non-granulomatous inflammatory disorder involving

the colon.

 

Both the diseases are unexplained (idiopathic) but some etiological

factors are implicated like:

Genetic (familial clustering is noted), infectious agent may be the cause (as

there is inflammation), or abnormal host immunoreactivity.

Feature Crohn’s disease Ulcerative colitis

Site Throughout the GIT The colon starting from the rectum

Distribution Skip lesion Continuous lesion

Stricture & Fibrosis Occurs early in the disease due to marked fibrosis

Rare/ occurs late as fibrosis is to a lesser degree

Wall Thickened Thin & Dilated

Ulcers Deep and linear Superficial

Fistulas Present Absent

Pseudopolyps Absent Present

Granulomas Present Absent

Extra intestinal manifestations

Arthritis, Ankylosing spondylitis Uveitis, Cholangitis and Erythema nodosum

Occur but to a lesser extent

Malignant potential & Prognosis

Definite riskPoor prognosis

Present but rarerGood prognosis

Fat & vitamin malabsorption

Present Absent