GASTROINTESTINAL

SYSTEM
Paul Tang, MD, DPAMS
 CLASSIFICATION OF GI DISEASES

1. Impaired Digestion and Absorption

2. Altered Secretion
3. Altered Gut Transit
4. Immune Dysregulation
 CLASSIFICATION OF GI DISEASES

5. Impaired Gut Blood Flow

6. Neoplastic Degeneration
7. Disorders without Obvious Organic
Abnormalities
8. Genetic Influences
 Impaired Digestion and Absorption

 Diseases of the stomach, intestine, biliary tree, and

pancreas can disrupt nutrient digestion and
absorption
 Gastric hypersecretory conditions damage the
intestinal mucosa and accelerate transit due to
excess gastric acid
 The most common intestinal maldigestion
syndrome, lactase deficiency, produces flatus and
diarrhea after dairy product ingestion and has no
other adverse outcomes
 Impaired Digestion and Absorption

 Biliary obstruction from stricture or neoplasm may

impair fat digestion
 Impaired release of pancreatic enzymes in chronic
pancreatitis or pancreatic cancer decreases
intraluminal digestion and can lead to profound
malnutrition
 Altered Secretion

 Gastric acid hypersecretion occurs in Zollinger-

Ellison syndrome, G-cell hyperplasia, retained
antrum syndrome, and in some individuals with
duodenal ulcer disease
 Conversely, patients with atrophic gastritis or
pernicious anemia release little or no gastric acid
 Inflammatory and infectious small-intestinal and
colonic diseases produce fluid loss through impaired
absorption or enhanced secretion but do not usually
cause malnutrition
 Altered Gut Transit

 Commonly secondary to mechanical obstruction

 Acid-induced stricture or neoplasm can cause
esophageal occlusion, gastric outlet obstruction
 Small-intestinal obstruction most commonly results
from adhesions but may also occur with Crohn’s
disease, radiation- or drug-induced strictures, and,
less likely, malignancy.
 Altered Gut Transit

 The most common cause of colonic obstruction is

colon cancer
 Inflammatory strictures can occur in inflammatory
bowel disease, after certain infections, or with some
drugs
 Altered Gut Transit

 Retardation of propulsion also develops from

disordered gut motor function
 Achalasia is characterized by impaired
esophageal body peristalsis and incomplete
lower esophageal sphincter relaxation
 Altered Gut Transit

 Gastroparesis is the symptomatic delay in gastric

emptying of solid or liquid meals
 Intestinal pseudoobstruction causes marked
delays in small bowel transit due to injury to
enteric nerves or intestinal smooth muscle
 Altered Gut Transit

 Slow transit constipation is produced by diffusely

impaired colonic propulsion
 Constipation is also produced by outlet
abnormalities (rectal prolapse, intussusception,
or failure of anal relaxation upon attempted
defecation)
 Altered Gut Transit

 Rapid gastric emptying occurs in postvagotomy

dumping syndrome and with gastric
hypersecretion
 Accelerated transit with hyperdefecation is
noted in hyperthyroidism
 Immune Dysregulation

 The mucosal inflammation of celiac disease results from

dietary ingestion of gluten-containing grains
 Eosinophilic gastroenteritis is an inflammatory condition
with prominent mucosal eosinophils
 Ulcerative colitis and Crohn’s disease are disorders of
uncertain etiology that produce mucosal injury primarily
in the lower gut
 Immune Dysregulation

 The microscopic colitides, lymphocytic and collagenous

colitis, exhibit colonic subepithelial infiltrates without
visible mucosal damage
 Bacterial, viral, and protozoal organisms may produce
ileitis or colitis in selected patient populations
 Impaired Gut Blood Flow

 Intestinal and colonic ischemia, which are

consequences of arterial embolus; arterial
thrombosis;
 Venous thrombosis; or hypoperfusion from
dehydration, sepsis, hemorrhage, or reduced cardiac
output
 Neoplastic Degeneration

 Esophageal cancer develops with chronic acid reflux

or in those with an extensive alcohol or tobacco use
history
 Small-intestinal neoplasms are rare and occur with
underlying inflammatory disease
 Anal cancers may arise with prior anal infection or
inflammation
 Neoplastic Degeneration

 Pancreatic and biliary cancers elicit severe pain,

weight loss, and jaundice and have poor prognoses
 Hepatocellular carcinoma usually arises from
chronic viral hepatitis or cirrhosis secondary to
other causes
 Most GI cancers are epithelial-derived
 Disorders w/o Obvious Organic Abnormalities

 The most common GI disorders show no

abnormalities on biochemical or structural testing
include irritable bowel syndrome (IBS), functional
dyspepsia, non-cardiac chest pain, and functional
heartburn
 Exaggerated visceral sensory responses to noxious
stimulation
 Disorders w/o Obvious Organic Abnormalities

 Symptoms in some may result from altered processing

of visceral pain sensations in the central nervous
system
 Patients with functional bowel abnormalities with
severe symptoms may have significant emotional
disturbances
 Abdominal Pain
 Abdominal pain results from GI disease and
extra-intestinal conditions
 Visceral pain is generally midline in location and
vague in character
 Parietal pain is localized and precisely described
 Common inflammatory diseases with pain
include peptic ulcer, appendicitis, diverticulitis,
IBD, and infectious enterocolitis.
 Abdominal Pain
 Other intra-abdominal causes of pain include
gallstone disease and pancreatitis.
 Non-inflammatory visceral sources include
mesenteric ischemia and neoplasia.
 The most common causes of abdominal pain are
IBS and functional dyspepsia.
 Heartburn, Nausea & Vomiting

 Heartburn, a burning substernal sensation is felt

to result from excess gastroesophageal reflux of
acid
 Nausea and vomiting are caused by GI diseases,
medications, toxins, acute and chronic infection,
endocrine disorders, labyrinthine conditions, and
central nervous system disease
 Heartburn, Nausea & Vomiting
 The best characterized GI etiologies relate to
mechanical obstruction of the upper gut;
however, disorders of propulsion including
gastroparesis and intestinal pseudoobstruction
also elicit prominent symptoms
 As with abdominal pain, IBS and functional
dyspepsia commonly present with nausea and
vomiting.
 Altered Bowel Habits

 Common complaints of patients with GI disease

 Constipation is reported as infrequent defecation,
straining with defecation, passage of hard stools,
or a sense of incomplete fecal evacuation
 Causes of constipation include obstruction, motor
disorders of the colon, medications, and
endocrine diseases such as hypothyroidism and
hyperparathyroidism
 Altered Bowel Habits

 Other etiologies include portal hypertensive

causes, malignancy, tears across the
gastroesophageal junction, and vascular lesions.
 Fecal mucus is common in IBS, while pus
characterizes inflammatory disease.
 Altered Bowel Habits

 Diarrhea is reported as frequent defecation,

passage of loose or watery stools, fecal urgency
or a similar sense of incomplete evacuation
 Steatorrhea develops with malabsorption
 GI Bleeding

 Upper GI bleeding presents with melena or

hematemesis
 Lower GI bleeding produces passage of bright red
or maroon stools
 Chronic slow GI bleeding may present with iron
deficiency anemia
 The most common upper GI causes of bleeding
are ulcer disease, gastroduodenitis, and
esophagitis
 GI Bleeding

 The most prevalent lower GI sources of

hemorrhage include hemorrhoids, anal fissures,
diverticula, and arteriovenous malformations
 Other causes include neoplasm, IBD, ischemia,
infectious colitis, and other vascular lesions
 GI Bleeding
Upper Gastrointestinal Tract
• Melena or hematochezia
• The most common causes
are ulcer disease,
gastroduodenitis, and
esophagitis
• Other etiologies include
portal hypertensive causes,
malignancy, tears across the
gastroesophageal junction,
and vascular lesions
Lower Gastrointestinal Tract
• Passage of bright red or
maroon stools
• Most prevalent lower GI
sources of hemorrhage
include hemorrhoids, anal
fissures, diverticula, and
arteriovenous malformations
• Other causes include
neoplasm, IBD, ischemia,
infectious colitis, and other
vascular lesions