1. GASTROINTESTINAL SYSTEM
CH 16
Goodman

2. INTRODUCTION
Upper GI (mouth, esophagus, stomach and duodenum) - ingestion and digestion
Lower GI: small intestines - digestion, absorption of nutrients; large intestines – absorbs water and electrolytes, stores waste products until elimination
Enteric nervous system - just as many nerves as the spinal cord; can function completely independent of the CNS; it is thought that the “brain in the bowel” can have its own form of neuroses (such as functional bowel syndromes)
PT needs to be aware of the clinical manifestations of GI issues - many have implications on physical activity tolerance and healing / recovery (dehydration, malnutrition, anemia)

3. Gastrointestinal System
Mouth>pharynx>esophagus>stomach>small intestine (duodenum, jejunum, ileum)>large intestine (cecum, ascending, transverse, descending, sigmoid) >rectum>anus
**liver, gallbladder and pancreas needed for digestion

4. Additional organs of digestion
Liver  The liver has multiple functions, but two of its main functions within the digestive system are to make and secrete an important substance called bile and to process the blood coming from the small intestine containing the nutrients just absorbed. The liver purifies this blood of many impurities before traveling to the rest of the body.

5. Additional organs of digestion
Gallbladder  The gallbladder is a storage sac for excess bile. Bile made in the liver travels to the small intestine via the bile ducts. If the intestine doesn't need it, the bile travels into the gallbladder, where it awaits the signal from the intestines that food is present. Bile serves two main purposes. First, it helps absorb fats in the diet, and secondly, it carries waste from the liver that cannot go through the kidneys.

6. Additional organs of digestion
Pancreas  Among other functions, the pancreas is the chief factory for digestive enzymes that are secreted into the duodenum, the first segment of the small intestine. These enzymes break down protein, fats, and carbohydrates.

7. Evolution of the appendix…in case you were wondering
Aug. 21, 2009 — The lowly appendix, long- regarded as a useless evolutionary artifact, won newfound respect two years ago when researchers at Duke University Medical Center proposed that it actually serves a critical function. The appendix, they said, is a safe haven where good bacteria could hang out until they were needed to repopulate the gut after a nasty case of diarrhea, for example.
*Has been regarded as a vestigial structure (one that has lost all or most of its original function through evolution)

8. Signs and symptoms of Gastrointestinal Disease
Nausea (symptom)
uneasy feeling - as if going to vomit - caused by irritation in nerve ending of stomach

9. Signs and symptoms… Vomiting (sign)
Flow of stomach contents backwards through upper GI......and either aspirated into lungs
or out the mouth (if back down the esophagus is technically just reflux)
Caused by anything that causes nausea
Complications include fluid and electrolyte imbalances, pulmonary aspiration --> aspiration
pneumonia; malnutrition; rupture of esophagus; dental decay (if prolonged)
If vomit is blood mixed with stomach acids looks like “coffee-grounds” and is aptly referred to as “coffee-ground vomit”

10. Signs and symptoms Diarrhea (sign)
Abnormal fluid mixture, frequency and/or volume of stool
Results in poor absorption of fluid, nutritive elements, and electrolytes

11. Signs and symptoms Anorexia (symptom vs. sign)
Diminished appetite or aversion to food
Anorexia - Cachexia (sign)
Anorexia that results in wasting of muscle; is a common systemic response to cancer
Associated with poor intake and high metabolic rate

12. Signs and symptoms Constipation (sign)
Fecal matter is too hard to pass easily; or when bowel movements are so infrequent that discomfort and other symptoms interfere with daily activities
May occur due to diet, dehydration, side effect of medication, acute or chronic disease of digestion system, inactivity or prolonged bed rest, emotional stress

13. Signs and symptoms Dysphagia (sign vs. symptom)
Difficulty swallowing that results in the sensation that food is stuck somewhere in the
throat or chest; may be a symptom / sign of many other disorders other than GI - such as
neurological conditions

14. Signs and symptoms Achalasia (sign vs. symptom)
Rare disorder that makes it difficult for food and liquid to pass from esophagus to stomach.
Due to loss of nerve cells in the esophagus so that food is not propelled down the GI tract
Also, the lower esophageal sphincter (LES) which connects the esophagus and the stomach doesn’t fully relax.
This results in a feeling of “fullness” in the sternal region that can progress to dysphagia

15. Signs and symptoms Heartburn (symptom)
Pain or burning sensation in the esophagus, can radiate to arms, jaw or back

16. Signs and symptoms Abdominal pain Inflammatory - due to inflammation
Mechanical - stretching of the walls of GI tract
Ischemic - due to buildup of metabolites that are released in an area of reduced blood flow

17. Signs and symptoms GI Bleeding
Accumulation of blood in GI tract is irritating and tends to cause discomfort; vomiting (Coffee ground vomit), diarrhea (black, tarry), or hematochezia (bleeding from rectum)

18. Signs and symptoms Fecal incontinence
Inability to control bowel movements
Psychological factors - confusion, anxiety, disorientation
Physiologic - neurological / motor impairment

19. Aging and the Gastrointestinal System
Changes begin before 50 y/o
Oral changes (tooth decay) may lead to difficulty with digestion
Sensory changes - decreased taste buds which can contribute to depressed appetite
Salivary secretions decrease - dry mouth, difficulty with digestion
Organs lose tone but manage to function well enough

20. Aging and Changes…
Net effect of changes includes decreased alimentary mobility (increased constipation),
decreased blood flow, decreased nutrient absorption> slower digestion and emptying
There is a decline in “Intrinsic Factor” (IF) that typically promotes vitamin B12 absorption
in the stomach; this frequently occurs after middle age. In advanced age (90 y/o), prevalence
of problems associated with B12 deficiency is as high as 90% (anemia, neurological symptoms, constipation, weight loss)

21. ESOPHAGUS Hiatal Hernia
Definition & Incidence: lower esophageal sphincter gets enlarged and stomach passes through the diaphragm into the thoracic cavity
Estimated incidence of 5/1000 people / year
Prevalence estimated at 60% of people over 60 y/o (symptomatic and asymptomatic)
Etiologic / risk factors - anything that weakens the diaphragm muscle or alters the hiatus
Pathogenesis / Clinical Manifestations: heart burn - worse when lying down or with increased abdominal pressure
Medical Management: diagnosed by ultrasound imaging or barium swallow with fluoroscopy; treatment includes symptomatic control

22. ESOPHAGUS Gastroesophageal Reflux Disease (esophagitis) (GERD)
Definition & Incidence: inflammation of esophagus; increasing incidence with aging;
15% or more of the population may have symptoms daily
Types: reflux, chemical, infectious
Etiologic / risk factors: backward flow of stomach acids; irritation by nasogastric intubation or radiation

23. ESOPHAGUS GERD (continued)
Pathogenesis / Clinical Manifestations: Heart burn, belching, dysphagia; problem is that
long term GERD can result in Barrett’s esophagus (metaplasia - dysplasia) which increases risk for neoplasia

24. ESOPHAGUS GERD (continued)
Medical Management: diagnosis with history, endoscopy, barium radiography, H-pylori, esophageal pH
Can be confused with angina; Nitroglycerin can help determine cardiac vs. GERD pain (but not without error - some GERD goes away with nitroglycerin)
Treatment includes acid suppression, lifestyle modifications - drinking fluids between
meals but not with meals, loose fitting clothes, avoiding caffeine, nicotine, alcohol, aspirin,
NSAIDs, remaining upright for at least 3 hours after meals, weight loss if obese
Minimally invasive surgery is being developed

25. ESOPHAGUS Mallory-Weiss Syndrome
Mucosal laceration of the lower end of esophagus accompanied by bleeding.
It is commonly caused by retching and vomiting due to alcohol abuse, eating disorders or a viral syndrome
Diagnosis is made with endoscopy
Treatment with fluid replacement, blood transfusion
Endoscopic ligation may be required

26. ESOPHAGUS Neoplasm Definition & Incidence
Two types - squamous cell and adenocarcinoma
Adenocarcinoma is relatively uncommon but incidence is rising (H-pylori treatment might be reason)
Etiologic / risk factors: irritation, any change in function that keeps food in the esophagus
longer than it should that results in ulceration and metaplasia

27. ESOPHAGUS Neoplasm (continued)
Clinical Manifestations - dysphagia is the primary sign / symptom, but it does not present until the esophagus is blocked between 30-50%; the only pain tends to be heartburn with lying down

28. ESOPHAGUS Neoplasm (continued)
Medical Management - prevention by treatment of irritation / GERD, etc.; diagnosis with endoscopy
Neoplasms are classified as resectable with curative intent, resectable but not
curable, and not resectable/not curable; (depends on metastases, lymph node involvement)
Prognosis is poor - 5 year survival is 10%, with a median survival of less than 10 months
(related to the lack of symptoms / signs until relatively late in the process)

29. ESOPHAGUS Esophageal Varices
Dilated veins in the lower third of esophagus immediately beneath the mucosa due to
portal hypertension usually associated with cirrhosis of the liver; usually painless but
significant bleeding that can result in anemia and other low blood volume problems (in
extreme cases shock)
About 1/2 cease without intervention; ligation may be needed; in extreme cases a stent
may be required to relieve portal hypertension

30. ESOPHAGUS Congenital Conditions
Tracheoesophageal Fistula TEF - most common congenital esophageal anomaly; about 1 in 4000 live births; esophagus fails to make connection to the stomach : might go to trachea and then stomach; or trachea alone; or just end blindly with or without trachea making a connection to stomach - requires surgical repair

31. ESOPHAGUS WHAT does this condition cause?? Depends on type
See page 840 in Goodman

32. Tracheoesophageal Fistula Note: 90-95% of cases are type C

33. STOMACH
Gastritis
Definition & Incidence - inflammation of the lining of the stomach; represents a group of the most common stomach disorders; can be acute or chronic; most common form of chronic gastritis is caused by a bacterial infection: H-pylori
Etiologic / risk factors: serious illness, medication use (ASA, NSAID), stress, H-pylori
Clinical Manifestations - epigastric pain; can lead to GI bleeding
Medical Management - Dx by history, endoscopy, biopsy, tests of stool or blood for H-pylori;
Rx, remove cause if possible, time to heal

34. STOMACH Peptic Ulcer Disease PUD
Definition & Incidence - break in protective mucosal lining which exposes submucosal areas to gastric contents/secretions
Two types – gastric (stomach) or duodenal (DUs are 2-3 x more prevalent)
Etiologic / risk factors: anything that causes gastritis
Clinical Manifestations: epigastric pain - with burning, gnawing, cramping, aching near xiphoid coming in waves; can include nausea, loss of appetite and weight loss.
Perforation causes increased pain in thoracic spine area T6-T11 with radiation to RUQ
Medical Management: Dx: same as gastritis; Rx - same as gastritis; surgical intervention is required for perforation

35. STOMACH Gastric Cancer
1. Primary gastric lymphoma (relatively uncommon)
2. Gastric Adenocarcinoma - malignant neoplasm originating from gastric mucosa
Etiologic / risk factors - chronic gastritis
Clinical Manifestations - - depends on variety of factors such as size of tumor, presence of gastric outlet obstruction, metastatic versus nonmetastatic disease
Medical Management - Dx is usually delayed due to symptomatic treatment of gastritis (early stages may be asymptomatic)
Surgery is treatment of choice; prognosis depends on stage when discovered

36. STOMACH Gastric cancer (continued)
Prevention: presently best advice is to eat at least 5 (1/2) cup servings of fruit and vegetables/daily combined with exercise, maintenance of healthy weight and reduced intake of salt-preserved foods

37. STOMACH Congenital Conditions
Pyloric Stenosis (PS) - obstruction of pyloric sphincter (stomach into duodenum)
Clinical Manifestations - projectile vomiting is the most common and dramatic early sign - and may occur at birth
Projectile vomiting requires vomit to eject 1 foot or more when supine, or 3-4 feet when upright
Medical Management - antispasmodic medications (if effective) for 6-8 months to see if
stenosis loosens up; if it does not loosen up surgical repair is required

38. INTESTINES Malabsorption Syndrome
Definition & Incidence - group of disorders (celiac disease, cystic fibrosis, Crohn’s
disease, chronic pancreatitis, pancreatic carcinoma, pernicious anemia, short gut syndrome, fibrotic changes due to gastroenteritis) characterized by reduced intestinal absorption
of dietary components and excessive loss of nutrients in the stool

39. INTESTINES Malabsorption syndrome (continued)
Traditionally classified as:
Maldigestion- failure of chemical process of digestion
Malabsorption- failure of intestinal mucosa to absorb nutrients
Can occur separately or together simultaneously

40. INTESTINES Malabsorption syndrome (continued)
Etiologic / risk factors - most often in therapy will see patients with gastroenteritis due to NSAID use and resultant fibrotic changes leading to malabsorption

41. INTESTINES Malabsorption syndrome (continued)
Clinical Manifestations - Progressive - related to nutrient deficiency
General malaise - weakness, fatigue, muscle wasting
B12 - pernicious anemia
Iron, vit A, D, K - osteomalacia
Calcium, vit D, magnessium - tetany
Vit B complex - Numbness and tingling
Electrolytes - muscle spasms, palpitations
Vit K - easy bruising / bleeding
Protein - generalized swelling

42. INTESTINES Malabsorption syndrome (continued)
Medical Management - treat underlying condition; nutritional supplementation – may need to bypass GI (parenteral nutrition - IV feeding); prognosis depends on underlying
condition

43. INTESTINES Vascular Diseases
Embolic occlusions of visceral branches of abdominal aorta
Intestinal Ischemia - caused by atherosclerosis or emboli; pain, rapid onset of cramping
Rx - surgery

44. INTESTINES Bacterial Infections
Food borne illnesses such as botulism are caused by bacteria. Can be fatal. Appropriate treatment depends on identifying pathogen. Many episodes of acute gastroenteritis need fluid replacement and supportive care.

45. INTESTINES Inflammatory Bowel Disease (IBD) Definition & Incidence -
1. Crohn’s disease (CD) - chronic, life long inflammatory disorder that can affect any segment of the intestinal tract with “skips” (sections of normal bowel with skips or lesions)
2. Ulcerative colitis (UC) - chronic inflammatory disorder of the mucosa of the colon in a continuous manner –chronic diarrhea and rectal bleeding

46. INTESTINES IBD (continued)
Etiologic / risk factors - both have unknown etiologies
Pathogenesis - both are considered autoimmune
Clinical Manifestations - recurrent involvement of intestinal segments resulting in a chronic, unpredictable course
Inflammatory process begins with low-grade fever, malaise, weight loss, diarrhea and abdominal cramping / pain; may be followed by obstructive phase with persistent bloating
and distention from the movement of gas through the system

47. INTESTINES IBD (continued)
Medical Management - Dx only by history and ruling out other conditions; monitoring includes use of radiographs, colonoscopy, barium enema x-ray, fecal occult blood tests, blood testing
Rx: symptom relief, anti inflammatory meds, diet, surgery to resect parts of intestine may be necessary

48. INTESTINES Antibiotic Associated Colitis
Antibiotics can disrupt normal GI bacterial flora; common for C - difficile (Clostridium difficile) to dominate; it is a microorganism that can replace normal GI tract flora
It is not invasive, but can create toxins that damage the colonic mucosa; signs start as a
lot of watery diarrhea - can occur early with antibiotic treatment or within 4 weeks after the medications have stopped.
Treatment is aimed at fluid and nutrition replacement, and antimicrobials can be prescribed to treat the c-diff

49. INTESTINES Irritable Bowel Syndrome (IBS)
Definition & Incidence - group of symptoms - most common disorder of the GI system -
Referred to as ‘nervous indigestion’, ‘spastic colon’, ‘nervous colon’ and ‘irritable colon’
There is absence of inflammation; it should not be confused with Crohn’s or Ulcerative colitis
(It is not as severe - there are no structural or biochemical defects identified)

50. INTESTINES IBS (continued)
Etiologic / risk factors - three main functional abnormalities: 1. altered GI motor activity;
2. visceral hypersensitivity; 3. altered processing of information by the nervous system

51. INTESTINES IBS (continued)
Clinical Manifestations - Abdominal pain that is relieved by a bowel movement, bloating,
distention, passage of mucus, changes in stool form (hard or loose and watery),
alterations in stool frequency, or difficulty in passing a movement
Medical Management - Dx - history; no test.
Rx aimed at symptoms, lifestyle changes (dietary), stress reduction, behavior therapy (to identify and reduce triggers)

52. INTESTINES Diverticular Disease
Diverticulosis - outpouchings in intestinal wall, uncomplicated
Diverticulitis - inflammed outpouching, complicated
Asymptomatic in 80% of people with diverticulosis; when inflammed - severe pain
Treatment to relieve symptoms, prevent diverticulitis; if diverticulitis may need antibiotics and complete rest of colon with naso gastric tube feedings and IV fluids until inflammatory process has been resolved

53. INTESTINES Diverticular disease (clarified)
*outpouching is called diverticula
The presence of diverticula in wall of colon or small intestine describes the herniation of mucosa through the muscles of the colon
It is when food particles or feces become trapped in diverticula and become infected and inflammed >>> diverticulitis
Rarely reversible

54. INTESTINES
Neoplasms
Intestinal Polyps - growth or mass in wall of intestines
Benign Tumors (most common adenomas, leiomyomas, lipomas) - Rarely become malignant; only need to be treated if causing symptoms
Malignant Tumors
Adenocarcinoma - (colorectal cancer) second leading cause of cancer death in US men and women combined; they have a long pre-invasive phase; few early warning signs - rely on medical screening with colonoscopy; persistent change in bowel habits is the single most consistent symptom
Rx: surgical removal

55. INTESTINES Obstructive Disease
Definition & Incidence - anything that reduces the size of the gastric outlet, preventing normal flow of chyme and delaying gastric emptying
Leads to: distention, cramping pain, tenderness that progresses to point of being constant, vomiting due to reflux, constipation, signs of dehydration, hypovolemia
After ~ 24 hours of complete obstruction, impaired blood supply can lead to necrosis and strangulation; can cause fever, leukocytosis, peritoneal signs or blood in feces

56. INTESTINES Obstructive Disease (continued)
Three causes: Organic, mechanical, functional
1. Organic: due to another condition

57. INTESTINES 2. Mechanical Obstruction
Adhesion - scar tissue from surgeries
Intussusception - telescoping of intestines on itself (Figure 16-17)
Volvulus - twisting
Hernia - protrusion of intestines through the groin, abdomen, navel (weakness in muscle and connective tissue normally containing it)

58. Mechanical Obstructions of Intestines

59. INTESTINES 3. Functional Obstruction
Adynamic or Paralytic Ileus - neurologic or muscular impairment of peristalsis
Oglvie’s Syndrome - Acute colonic pseudo- obstruction early postoperatively
following trauma to hip, pelvis, or after elective hip or pelvic surgery; etiology
unknown - but thought to be related to disruption to sacral parasympathetic nerves (S2-S4 supply colon and rectum)

60. INTESTINES Congenital Conditions
Stenosis & Atresia - stenosis - narrowing of small intestine; atresia is a defect
caused by incomplete formation of lumen
Meckels Diverticulum - outpouching of the bowel located at the ileum of small
intestine

61. APPENDIX- appendicitis
Definition & Incidence - inflammation of the vermiform appendix that often results in necrosis and perforation and subsequent peritonitis
Etiologic / risk factors - 1/2 no known cause; 1/3 due to obstruction of some type that prevents drainage (what is the other 1/6 is caused by?)
Pathogenesis - obstruction -> infection; or just infection
Clinical Manifestations - constant pain RLQ, n&v ; children - fever; adults - mild fever; aggravated
by anything that increase abdominal pressure
Can present atypically
“Pinch an inch” test > rebound test
Medical Management - remove appendix

62. PERITONEUM Peritonitis
Definition & Incidence - inflammation of peritonium – serous membrane lining the wall of abdominal cavity; if
spontaneous >primary; if due to trauma, surgery, peritoneal contamination from a perforation > secondary.
Etiologic / risk factors - primary ?; secondary, trauma, surgery, GI issue that leads to perforation
Clinical Manifestations - decreased GI motility and distention with gas; vague generalized abdominal pain; as progresses becomes severe pain and abdomen becomes rigid (involuntary guarding), n&v, fever
Medical Management - infection control, and treat consequences

63. RECTUM AND ANUS Rectal (or anal) Fissure
Ulceration or tear of lining of the anal canal - usually caused by excessive tissue stretching
or tearing such as during childbirth or a large, hard bowel movement; tends to re- open frequently
Heal within a month or two - may need stool softeners to help facilitate healing by preventing re injury

64. RECTUM Rectal Abscesses and Fistulas
Abscesses (infection) or fistula (opening) can occur as a result of an infected anal gland,
fissure or prolapsed hemorrhoid and are most common in people with Crohn’s disease

65. RECTUM and/or ANUS Hemorrhoids “piles”
Varicose veins of a pillow like cluster of veins that lie just beneath the mucus membrane
at the lowest part of the rectum - associated with anything that increases intra-abdominal
pressure (Box 16-1); internal hemorrhoids may require ligation (tying up), sclerosing (shrinking the vessels) , laser or cryosurgery to destroy the tissue; external can be treated with local applications of topical medications, high fiber diet, avoidance of constipation

66. Resources/references
1. The Digestive System Diagram, Organs, Function, and More - WebMD
2. Upper GI Tract Anatomy - eMedicine World Medical Library
emedicine.medscape.com/article/ overview‎
3. Gut. 2004 February; 53(2): 310–311.
4. Evolution Of The Human Appendix: A Biological 'Remnant' No More
htm‎
5. Achalasia — Diagnosis and treatment at Mayo Clinic

67. Emotional Support Animals

68. Emotional Support Animals
Andrea C. Mendes PT, DPT
Sean M. Collins PT, ScD