GASTROINTESTINAL SYSTEM BLOCK

PROBLEM 1

LO 1
MM ANATOMY,HISTOLOGY & BIOCHEMISTRY
SALURAN PENCERNAAN ATAS

HISTOLOGY

DIGESTIVE SYSTEM
Two groups of organs compose the
digestive system:
Gastrointenstinal (GI) tract or alimentary
canal mouth, most of pharynx,
esophagus, stomach, small intestine,
and large intestine
Accessory digestive organs teeth,
tongue, salivary glands, liver,
gallbladder, and pancreas
diFiore Atlas of Histology, 247

Histologic organization:
Mucosa:
Epithelium, lamina propria, muscularis mucosa
Submucosa:
connective tissue, vessels, and Meissners plexuses,
some times mucous glands
Muscularis externa: 2-3 layers of smooth muscle (plus
skeletal muscle in esophagus), myenteric (Auerbach)
plexus in between muscle layers
Serosa and adventitia: Outermost layer of loose
connective tissue and blood vessels. Call serosa if
covered my mesothelium; adventitia otherwise

mucosa

submuco

muscula

serosa

ORAL CAVITY
Inner surface of the lips, cheeks, soft
palate, surface of tongue, and floor of the
mouth
Nonkeratinized stratified squamous epithelium
Lamina propria
Submucosa

Gingiva and hard palate

Keratinized stratified squamous epithelium
Lamina propria

Tongue: specialized mucosa with papillae

THE LIP

THE TONGUE

Junquiera, L. C. (2013) Basic Histology text & Atlas, 13rd edn.

McGraw Hill, New York.

TONGUE PAPILLAE

There are four types:

fungiform

filliform

foliate

circumvall
ate

TASTE BUD

TEETH

Lower esophagus

Upper esophagus

LO 2
MM FISIOLOGI MENELAN

The Digestive System

The primary function of the digestive
system is to transfer nutrients,
water, and electrolytes from the food
we eat into the bodys internal
environment.
There are four basic digestive
processes : motility, secretion,
digestion, and absorption.

 The digestive system consists of the

digestive tract plus the accessory
digestive organs.
The accessory digestive organs
include the salivary glands, the
exocrine pancreas, and the biliary
system , which is composed of the
liver and gallbladder.
The digestive tract wall has four
layer. From the innermost layer
outward, they are the mucosa, the
submucosa, the muscularis externa,

 Four factors are involved in

regulating digestive system
function :
1. Autonomous smooth muscle
function
2. Intrinsic nerve plexuses
3. Extrinsic nerves
4. GI hormones

Mouth
Entry to the digestive tract is through
the mouth or oral cavity. The opening
is formed by the muscular lips.
The palate , which forms the arched
roof of the oral cavity, separates the
mouth from the nasal passages.
The tongue, which forms the floor of
the oral cavity, is composed of
voluntarily controlled skeletal muscle.

 The first step in the digestive process

is mastication, or chewing, the
motility of the mouth that involves
the slicing,tearing, grinding, and
mixing of ingested food by the teeth.
Saliva, the secretion associated with
the mouth, is produced largely by
three major pairs of salivary glands
that lie outside the oral cavity and
discharge saliva through short ducts
into the mouth.

 The most important salivary proteins are

amylase, mucus, and lysozyme. They
contribute to the functions of saliva, which
are as follows :
1. Saliva begins digestion of dietary starches
through action of the enzyme salivary
amylase.
2. Saliva facilitates swallowing by moistening
food particles, there by holding them
together.
3. Saliva exerts some antibacterial action by
a fourfold effect-first, by lysozyme.

4. Saliva serves as a solvent for molecules

that stimulate the taste buds.
5. Saliva aids speech by facilitating
movements of the lips and tongue.
6. Saliva plays an important role in oral
hygiene by helping keep the mouth and
teeth clean.
7. Saliva is rich in bicarbonate buffers,
which neutralize acids in food and acids
produced by bacteria in the mouth.

 Salivary secretion is continuous and

can be reflexly increased.
On average, about 1 to 2 liters of
saliva are secreted per day.
Salivary secretion may be increased
by two types of salivary reflexes,
simple and conditioned.

Pharynx and Esophagus

The motility associated with the
pharynx and esophagus is
swallowing.
Swallowing actually is the entire
process of moving food from the
mouth through the esophagus into
the stomach.
The two stages of swallowing : the
oropharyngeal stage and the
esophangeal stage.

LO 3
MM PENYAKIT
MENYEBABKAN DISFAGIA
( SWELLING)

Dental Caries (Tooth Decay)

Definition

Is a common problem that occurs when acids in your

mouth dissolve the outer layers of your teeth. (*)

Epidemiolo
gy

Children aged 6 to 11 years and adolescents aged 12

to 19 years. Dental caries also affects adults, with 9
out of 10 over the age of 20 having some degree of
tooth-root decay. (**)

Etiology

Bacteria (***)

Risk Factor

Diet (food & drink high in carbohydrats), poor oral

hygiene,
Smoking and alcohol, dry mouth (***)

Sign &
Symptoms

Toothache, tooth sensitivity(tenderness or pain), grey,

brown or black spots, bad breath, an unpleasant taste
in mouth (*)

Physical
Examinatio
n

The early sign: chalky white appearance of theenamel

surface.
If the caries progresses: enamel surface becomes dark
brown or black.

Dental Caries (Tooth Decay)

Pathogenesis (*)
Mouth full
of bacteria
Consume
carbohydra
ts
Plaque and
bacteria will enter
the pulp (contains
nerves and blood
vessels
Toothache

Bacteria in plaque
turn the
carbohydrates
energy they need
+ producing acid
The process of
tooth decay speeds
up.

The plaque soften the

enamel, by removing
minerals from the
tooth
The plaque and
bacteria can
reach the dentine

Dental Caries (Tooth Decay)

Treatment
s

Flouride: early stage

Fillings and crowns: if the decay is more extensive
replaces your missing enamel
Root canal treatment: if tooth decay has spread to the
pulp (the soft centre of the tooth) the pulp may have
to be removed and replaced with an artificial pulpthat
will keep the tooth in place
Tooth extraction: tooth may beremoved to prevent the
spread of infection. (*)

Complicati
ons

Gum disease (gingivitis), dental abscesses (**)

Prognosis

Depends on the health of the patient, oral health

practices and the extent of dental caries (***)

Prevention Brush twice a day with a fluoride toothpaste

Clean the teeth daily with floss or interdental cleaner
Eat nutritious and balanced meals and limit snacking
Visit your dentist regularly for professional cleanings
and oral examination

Glossitis
Definition

Glossitis is a problem in which the tongue is swollen

and changes color, often making the surface of the
tongue appear smooth. (*)

Etiology

Allergic reactions to oralcare products, foods, or

medicine
Dry mouth due to Sjogren syndrome
Infection from bacteria, yeast or viruses (including
oral herpes)
Injury (such as from burns, rough teeth, or badfitting dentures0
Skin conditions that affect the mouth
Irritants such as tobacco, alcohol, hot foods, spices,
or other irritants
Hormonal factors. (*)

Sign &
Symptoms

Problems chewing, swallowing, or speaking

Smooth surface of the tongue
Sore, tender, or swollen tongue

Treatmen
ts

Good oral care. Brush your teeth thoroughly at

least twice a day and floss at least once a day.
Antibiotics or other medicines to treat infection.
Diet changes and supplements to treat nutrition
problems.
Avoiding irritants (such as hot or spicy foods,
alcohol, and tobacco) to ease discomfort. (*)

Prognosis Good oral care (thorough tooth brushing and

flossing and regular dental checkups) may help
prevent glossitis(*)

Micrognathia &
macrognathia
1. Micrognathia a severely deficient jaw, most
commonly affects the mandible.
Types:
- Apparent micrognathia: this is not due to abnormality
of small jaw, in terms of size but rather due to an
abnormal positioning or abnormal relation of one jaw
to another, which produces illusion of micrognathia
- True micrognathia: it is due to small jaw. It is again
classified as:
a. Congenital
b. Acquired

Sumber: Textbook of Oral Medicine 3th edition, 2014

Etiology
Congenital:
- Congenital abnormalities: in
many instances, it is associated
with other congenital
abnormalities, particularly
congenital heart disease and
Pierre Robin syndrome (cleft
palate, micrognathia and
glossoptosis)
- Forceps delivery trauma: the use
of forceps on either side of the
head. If the joint, in this area,
called the temporomandibular
joint, is badly bruised, the
mandible does not develop

Acquired:

Ankylosis
Mouth breathing
Agenesis of condyle
Posterior positioning

Sumber: Textbook of Oral Medicine 3th edition, 2014

 Signs and Symptomps

- Short upper jaw
- Abnormal alignment of teeth

Sumber: Textbook of Oral Medicine 3th edition, 2014

 Management:
- Orthognathic surgery: recommended
treatment modality for micrognathia.
This surgery is followed by
orthodontic appliance to correct
malocclusion

Sumber: Textbook of Oral Medicine 3th edition, 2014

2. Macrognathia refers to the condition of

abnormally large jaws. It is also called as
megagnathia.
Etiology:
- Pituitary gigantism: there is generalized
increase in the size of entire skeleton
- Pagets disease of bone: overgrowth of
cranium and maxilla occurs
- Acromegaly: progressive enlargement of
mandible owing to hyperpituitarism in adults
Sumber: Textbook of Oral Medicine 3th edition, 2014

 Clinical features:
- prognathism: mandibular protrusion or proganthism is common
occurrence, which is due to disparity in the size of maxilla to
mandible and posterior positioning of maxilla in relation to the
cranium
- Mandible: mandible is measurably larger than normal. Increased
mandibular body length
- Gummy smile: in certain patients with congenital abnormalities,
there may be elongation of maxilla. There is much show when
the patient smiles, so that there is so-called gummy smile.
This is due to the upper jaw being too long
- Ramus: large ramus which forms less step angle with body of
mandible
- Chin: there is prominent chin button
Sumber: Textbook of Oral Medicine 3th edition, 2014

 Management:
- Osteotomy: resection of portion of
mandible to decrease the length,
followed by orthodentic treatment

Sumber: Textbook of Oral Medicine 3th edition, 2014

LO 4
MM PENYAKIT ( WHITE
PATCHES )

Oral Candidiasis
Definition A condition in which candida albicans accumulates
on the lining of your mouth. (*)
Symptom -Creamy white lesions on your tounge, inner cheeks,
s
and sometimes on The roof of your mouth, gums,
and tonsils
- A cottage cheese-like appearance
- Redness or soreness
- Slight bleeding
- Cracking and redness at the corner of your mouth
- A cottony feeling in your mouth
- Loss of taste (**)
-Some health conditions HIV/AIDS, cancer, DM,
Risk
Factors
vaginal yeast
Infections
- Undergoing chemotherapy or radiation treatment
for cancer
- Wearing dentures

Diagnosis

Limited to your mouth looking at the lesions

In your esophagus throat culture (swabbed with
sterile cotton), endoscopic exam (*)

Treatment - Patient with late-stage HIV infection amfotericin

B
- Practice good oral hygiene
- Try warm saltwater rinses. (**)
Preventio
n

Rinse your mouth

Brush your teeth at least twice a day and floss daily
Clean your dentures
See your dentist regularly
Watch what you eat
Maintain good blood sugar control if you have DM
Treat any vaginal yeast infections (***)

Leukoplakia
Definition

Leukoplakia is a white patch that develops in the

mouth. (*)

Epidemiol
ogy

OL occurs in fewer than 1% of individuals.

OL is more common in men than in women (2:1)
(*)

Etiology

Idiopathic (**)

Risk
Factor

tobacco use, alcohol consumption, chronic

irritation, candidiasis, vitamin deficiency,
endocrine disturbances, and possibly a virus. (**)

Sign &
Symptom
s

a white patch in the mouth that can't be

removed by rubbing. (***)

Homogenous
leukoplakia of the
lingual versant of the
gingiva

Verrucous leukoplakia
on the floor of the
mouth

Speckeled
leukoplakia on the
right retrocomisural
mucosa in a hard

Nodular leukoplakia of
the soft palate

Treatments of Leukoplakia
The main objective in
oral leukoplakia's
management of care is
to detect and to
prevent malignant
transformation.
the ceasing of the risk
activities such as
smoking
histopathological
evaluation
surgical treatment

The medical treatment

uses local and systemic
chemopreventive agents
such as:

vitamin A and retinoids,

systemic beta carotene,
lycopene (a carotenoid),
ketorolac (as mouthwash),
local bleomycin, and
a mixture of tea used both
topically and systemically
with a reduced benefit

LO 5
MM PENYAKIT ( HEREDITARY )

Esophageal Atresia
Definition

Esophageal atresia is a congenital defect

The upper esophagus ends and does not connect
with the lower esophagus and stomach.
Tracheoesophageal fistula (tef) is a condition in
which an abnormal channel(fistula) connect the
windpipe (tracea) to the tube that leads ffrom the
mouth to the stomach ( esophagus)

Sign &
Symptoms

Bluish coloration to the skin (cyanosis) with

attempted feedings
Coughing, gagging, and choking with attempted
feeding
Drooling
Poor feeding

Lab
Prenatal ultrasound
Investigati Chest x-rays and other x-rays
on
A special chest x-ray that is done after a
nasogastric tube is put through the nose into the

Esophageal atresia classification according to Gross of

Boston :

Type A - Esophageal atresia without fistula or so-called pure

esophageal atresia (10%)
Type B - Esophageal atresia with proximal TEF (< 1%)
Type C - Esophageal atresia with distal TEF (85%)
Type D - Esophageal atresia with proximal and distal TEFs (<
1%)
Type E - TEF without esophageal atresia or so-called H-type
fistula (4%)
Type F - Congenital esophageal stenosis (< 1%)

Esophageal Atresia
Treatment
s

Esophageal atresia is considered a surgical

emergency

Complicati The infant may breathe saliva and other fluids

ons
into the lungs aspiration pneumonia, choking,
and possibly death.
Other complications may include:
Feeding problems
Reflux (the repeated bringing up of food from
the stomach) after surgery
Narrowing (stricture) of the esophagus due to
scarring from surgery

Achalasia
Definition

Achalasia is a primary esophageal motility

disorder characterized by the absence of
esophageal peristalsis and impaired relaxation of
the lower esophageal sphincter (LES) in response
to swallowing. (*)

Epidemiol
ogy

more common in middle-aged or older adults.

(**)

Etiology

Unknown: viral infection may be responsible

Assosiated with autoimmune condition: Sjogren's
syndrome,lupusoruveitis. (**)

Sign &
Symptom
s

Dysphagia (most common), Regurgitation, Chest

pain , Heartburn, Weight loss. (***)

Lab
Barium swallow
Investigat Esophageal manometry (the criterion standard)
ion
Prolonged esophageal pH monitoring

Achalasia:
Treatments
Pharmacologic and other
nonsurgical treatments

Surgical treatment

Administration of calcium
channel blockers and nitrates
decrease LES pressure
(primarily in elderly patients
who cannot undergo
pneumatic dilatation or
surgery)
Endoscopic intrasphincteric
injection of botulinum toxin to
block acetylcholine release at
the level of the LES (mainly in
elderly patients who are poor
candidates for dilatation or
surgery)

Laparoscopic Heller
myotomy, preferably with
anterior (more common)
or posterior (Toupet)
partial fundoplication
Peroral endoscopic
myotomy (POEM)
Patients in whom surgery
fails may be treated with
an endoscopic dilatation
first

LO 6
MM PENYAKIT (MOUTH
ULCER )

Mouth Ulcers
Definition

Canker sores or mouth ulcers are normally small

lesions that develop in your mouth or at the base of
your gums. They are annoying and can make eating,
drinking, and talking uncomfortable. (*)

Etiology

Canker sores, Gingivostomatitis, Herpes simplex (fever

blister), Leukoplakia, Oral cancer, Oral lichen planus,
Oralthrush. (**)

Sign &
Symptoms

A painful sore or sores inside your mouth -- on

thetongue, on the soft palate (the back portion of the
roof of your mouth), or inside your cheeks
A tingling or burning sensation before the sores appear
Sores in your mouth that are round, white or gray, with
a red edge or border
In severe canker sore attacks, you may also
experience: Fever, Physical sluggishness, Swollen
lymph nodes (***)

Types of Mouth Ulcers

Simple canker sores.These may
appear three or four times a year and
last up to a week. They typically
occur in people between 10 and 20
years of age.
Complex canker sores.These are
less common and occur more often in
people who have previously had
them.

 Mouth ulcers also can be a sign of

conditions that are more serious and
require medical treatment, such as:
celiac disease (a condition in which the
body is unable to tolerate gluten)
inflammatory bowel disease (IBD)
Bechets disease (a condition that causes
inflammation throughout the body)
a malfunctioning immune system that
causes your body to attack the healthy
mouth cells instead of viruses and bacteria
HIV/AIDs

Treatments of Mouth Ulcers

TREATMENTS
using a rinse of
saltwater and baking
soda
covering mouth ulcers
with baking soda paste
using over-the-counter
benzocaine products like
Orajel or Anbesol
applying ice to canker
sores
using mouth rinse that
contains a steroid to
reduce pain and swelling

placing damp tea bags on

your mouth ulcer
cauterizing or burn sealing
the tissue with a chemical
cauterizer like silver
nitrate
taking nutritional
supplements like folic
acid, vitamin B6, vitamin
B12, and zinc
trying natural remedies
such as chamomile tea,
echinacea, myrrh, and
licorice
using oral steroids

Mouth Ulcers
Complication

Prevention

Cellulitis of the mouth,

from secondary bacterial
infection of ulcers
Dental infections (tooth
abscesses)
Oral cancer
Spread of contagious
disorders to other people

There are steps you can take to reduce

the occurrence of mouth ulcers.
Avoiding foods that irritate your mouth
can be helpful. That includes :
Acidic fruits like pineapple, grapefruit,
oranges, or lemon, as well as nuts,
chips, or anything spicy. Instead,
choose whole grains and alkaline
(nonacidic) fruits and vegetables.
Try to avoid talking while you are
chewing your food. Reducing stress and
maintaining good oral hygiene and
brushing after meals
Soft bristle toothbrushes and
mouthwashes that contain sodium
lauryl sulfate.