GASTROINTESTINAL SYSTEM BLOCK

PROBLEM 3
ALMIRA NABILA VALMAI
405130193

1.

LO

LO 1

HUBUNGAN SUHU
DENGAN HR

LO 2

DISTENSI DENGAN
PALPASI DALAM

 Deep palpation of the abdomen is performed by

placing the flat of the hand on the abdominal wall and
applying firm, steady pressure. It may be helpful to
use two-handed palpation (Figure 93.2), particularly
in evaluating a mass. Here the upper hand is used to
exert pressure, while the lower hand is used to feel.
One should start deep palpation in the quadrant
directly opposite any area of pain and carefully
examine each quadrant. At each costal margin it is
helpful to have the patient inspire deeply to aid in
palpation of the liver, gallbladder, and spleen.
Entire abdomen: (6 fs: fat, flatus, feces, fluid, fetus,
fatal cancer): may be sign of obstruction Lower half:
pregnancy, full bladder, ovarian tumor, uterine
fibroids (common benign growths)

LO 3

CRAMP ABDOMINAL PAIN

 Crampingis a type of pain that comes and

goes (intermittent) or that changes in position
or severity. Cramping is rarely serious if it is
relieved by passing gas or a stool. Many
women have cramping pain with their
menstrual periods. Generalized cramping pain
is usually not a cause for concern unless it
gets worse, lasts for longer than 24 hours, or
localizes. Cramping that starts suddenly with
diarrhea or other minor health problems can
be quite painful but is usually not serious.

LO 4

COATED TONGUE

 A coated or white tongueoccurs

when the surface is colonised by
bacteria or fungi, and dead cells
become trapped between the small
nodules on the tongue.

LO 5

ANATOMI, HISTOLOGI,
FISIOLOGI SALURAN
PENCERNAAN BAWAH

Small Intestine
90% of absorption occurs in the small
intestine

Small Intestine
The Jejunum
Is the middle segment of small intestine
2.5 meters (8.2 ft) long
Is the location of most
Chemical digestion
Nutrient absorption

Has few plicae circulares

Small villi

Small Intestine
The Ileum
The final segment of small intestine
3.5 meters (11.48 ft) long
Ends at the ileocecal valve, a sphincter
that controls flow of material from the
ileum into the large intestine

Small Intestine
Intestinal Secretions
Watery intestinal juice
1.8 liters per day enter
intestinal lumen
Moisten chyme
Assist in buffering acids
Keep digestive enzymes
and products of
digestion in solution

Intestinal Movements
Chyme arrives in
duodenum
Weak peristaltic
contractions move it
slowly toward jejunum
Myenteric reflexes
Not under CNS control
Parasympathetic
stimulation accelerates
local peristalsis and
segmentation

Coordination of Secretion & Absorption

Coordination of Secretion & Absorption

Intestinal Absorption
It takes about 5 hours for materials
to pass from duodenum to end of ileum
Movements of the mucosa increases
absorptive effectiveness
Stir and mix intestinal contents
Constantly change environment around
epithelial cells

Large Intestine
Is horseshoe shaped
Extends from end of ileum to anus
Lies inferior to stomach and liver
Frames the small intestine
Also called large bowel
Is about 1.5 meters (4.9 ft) long and 7.5
cm (3 in.) wide

Large Intestine Functions

Reabsorption of
water
Compaction of
intestinal contents
into feces
Absorption of
important vitamins
produced by bacteria
Storage of fecal
material prior to
defecation

Parts of Large Intestine

The Cecum

Is an expanded pouch
Receives material
arriving from the ileum
Stores materials and
begins compaction

Appendix
Also called vermiform
appendix
Is a slender, hollow
appendage about 9 cm
(3.6 in.) long
Is dominated by lymphoid
nodules (a lymphoid

Parts of Large Intestine

The Colon
Has a larger diameter and thinner wall
than small intestine
The wall of the colon
Forms a series of pouches (haustra)

Haustra permit expansion and

elongation of colon

Parts of Colon
Ascending Colon
Begins at superior border of cecum
Ascends along right lateral and posterior wall of
peritoneal cavity to inferior surface of the liver and
bends at right colic flexure (hepatic flexure)

Transverse Colon
Crosses abdomen from right to left; turns at left
colic flexure (splenic flexure)
Is supported by transverse mesocolon
Is separated from anterior abdominal wall by
greater omentum

Parts of Colon
The Descending Colon
Proceeds inferiorly along left side to the iliac
fossa (inner surface of left ilium)
Is retroperitoneal, firmly attached to abdominal
wall

The Sigmoid Colon

Is an S-shaped segment, about 15 cm (6 in.)
long
Starts at sigmoid flexure
Lies posterior to urinary bladder
Is suspended from sigmoid mesocolon
Empties into rectum

Parts of Colon

Parts of Large Intestine

The Rectum

Forms last 15 cm (6 in.) of

digestive tract
Is an expandable organ for
temporary storage of feces
Movement of fecal material
into rectum triggers urge to
defecate

The anal canal is the last

portion of the rectum

Contains small longitudinal folds

called anal columns

Anus

Also called anal orifice

Is exit of the anal canal
Has keratinized epidermis like
skin

Physiology of the Large

Intestine
Absorption in the Large Intestine
Reabsorption of water
Reabsorption of bile salts
In the cecum
Transported in blood to liver

Absorption of vitamins produced by

bacteria
Absorption of organic wastes

Physiology of the Large

Intestine
Three Vitamins Produced in the Large
Intestine
1. Vitamin K (fat soluble):

Required by liver for synthesizing four clotting

factors, including prothrombin

2. Biotin (water soluble):

Important in glucose metabolism

3. Pantothenic acid: B5 (water soluble):

Required in manufacture of steroid hormones and

some neurotransmitters

Physiology of the Large

Intestine
Organic Wastes
Bacteria convert bilirubin to urobilinogens
and stercobilinogens
Bacteria break down peptides in feces and
generate
Ammonia, Indole & skatole, hydrogen sulfide

Bacteria feed on indigestible carbohydrates

(complex polysaccharides)
Produce flatus, or intestinal gas, in large
intestine

Movements of the Large

Intestine

Gastroileal & gastroenteric

reflexes

Movements from transverse

colon through rest of large
intestine results from powerful
peristaltic contractions (mass
movements)

Stimulus is distension of
stomach and duodenum;
relayed over intestinal nerve
plexuses

Distension of the rectal wall

triggers defecation reflex

Move materials into cecum

while you eat
Movement from cecum to
transverse colon is very slow,
allowing hours for water
absorption
Peristaltic waves move material
along length of colon
Segmentation movements
(haustral churning) mix
contents of adjacent haustra

Two positive feedback loops

Both loops triggered by
stretch receptors in rectum

LO 6

KELAINAN SALURAN
PENCERNAAN BAWAH

DIARRHEA
Definition
clinically, diarrhea defined as stools that are looser
and/or more frequent than normal; or 24 h stool weight
>200 g (physiological definition, less useful clinically)

Classification
acute vs. chronic
small volume (tablespoons of stool; typical of colonic
diseases) versus large volume (>1/2 cup stool; typical
of small bowel diseases)
watery (bowel disease) vs. steatorrhea
secretory (diarrhea persists with fasting) vs. osmotic
(diarrhea stops with fasting)

ACUTE DIARRHEA
Definition
passage offrequent unformed stools for <14 d

Etiology
most commonly due to infections
most infections are self-limiting and resolve within 7 d

Risk Factors
food (seafood, chicken, turkey, eggs, beef)
medications: antibiotics, laxatives
others: high risk sexual activity, infectious outbreaks, family history (IBD)

Classification
broadly divided and classified into inflammatory and non-inflammatory
diarrhea
mechanisms: stimulation of intestinal water secretion and inhibition of water
absorption (i.e. secretory problem)
in inflammatory diarrhea, organisms and cytotoxins invade mucosa, killing
mucosal cells, further perpetuating the diarrhea

 Investigations
stool cultures/microscopy (C&S/O&P)
C&S only tests Campylobacter, Salmonella, Shigella,
E. Coli other organisms must be ordered separately
flexible sigmoidoscopy: useful if inflammatory
diarrhea suspected
biopsies are the most useful method of distinguishing
idiopathic IBD (Crohn's disease and ulcerative colitis)
from infectious colitis or acute self-limited colitis
C. difficile toxin: indicated when recent/remote
antibiotic use, hospitalization, nursing home or recent
chemotherapy

 Treatment
Fluid and electrolyte replacement orally in most cases, intravenous if
severe extremes of age/coma
anti-diarrheals
antimotility agents: diphenoxylate, loperamide (Imodium);
contraindicated in mucosal inflammation
side effects: abdominal cramps, toxic megacolon

absorbants: kaolin/pectin (Kaopectate), methylcellulose,

activated attapulgite
act by absorbing intestinal toxins/micro-organisms, or by coating
intestinal mucosa
much less effective than antimotility agent

modifiers of fluid transport: bismuth subsalicylate (Pepto-Bismol)

may be helpful
antibiotics: rarely indicated
risks
prolonged excretion of enteric pathogen (especially Salmonella)
drug side effects (including C. difficile infection)
development of resistant strains

indications for antimicrobial agents in acute diarrhea:

Septicemia
prolonged fever with fecal blood or leukocytes
clearly indicated: Shigella, V. cholerae, C. difficile, traveller's diarrhea
(enterotoxigenic E. coli (ETEC)), Giardia, Entamoeba histolytica,
Cyclospora
situational: Salmonella, Campylobacter, Yersinia, non-enterotoxigenic E.

CHRONIC DIARRHEA

Definition
passage of frequent unformed stool for >14 d
differential is similar to that of acute diarrhea, except that the majority
of cases are non-infectious

Etiology I Classification

Investigations
Guided by history
stool analysis for: C. difficile toxin, C&S, O&P fecal fat, WBC
blood for: CBC, chemistry, CRP, TSH, celiac serology (anti-tTG, protein
electrophoresis)
colonoscopy and ileoscopy with biopsy
Small bowel biopsy
upper GI endoscopy with duodenal biopsy
wireless small bowel endoscopy capsule (last resort - very costly)
rial of lactose free diet
may delay diagnosis of IBD and celiac disease

Maldigestion &
malabsorbtion
Definition
maldigestion: inability to break down
large molecules in the lumen of the
intestine into their component small
molecules
malabsorption: inability to transport
molecules across the intestinal mucosa
to the circulation
malassimilation: encompasses both
maldigestion and malabsorption

 Etiology
Maldigestion
inadequate mixing of food with enzymes (e.g. post-gastrectomy)
pancreatic exocrine deficiency
primary diseases of the pancreas (e.g. cystic fibrosis, pancreatitis, cancer)
Bile salt deficiency
terminal ileal disease (impaired recycling), bacterial overgrowth (deconjugation ofbile salts),
rarely liver disease (cholestatic)
specific enzyme deficiencies (e.g. lactase)

Malabsorption

inadequate absorptive surface

immunologic or allergic injury (e.g. celiac disease)
infections/infestations (e.g. Whipple's disease, giardiasis)
infiltration (e.g. lymphoma, amyloidosis)
fibrosis (e.g. systemic sclerosis, radiation enteritis)
bowel resection
extensive Crohn's disease

drug-induced
cholestyramine, ethanol, neomycin, tetracycline and other antibiotics

Endocrine
e.g. diabetes (complex pathogenesis)

 Clinical Features
Symptoms usually vague unless disease
is severe
weight loss, diarrhea, steatorrhea,
weakness, fatigue
manifestations of
malabsorption/deficiency

 Investigations
72 h stool collection (weight, fat content)
serum carotene, folate, Ca2+, Mg2+, vitamin B12,
albumin, ferritin, serum iron solution, INR/PTT
stool fat globules on fecal smear stained with
Sudan (rarely used)
other tests specific for etiology (e.g. CT scan/MRI
to visualize pancreas)
trial of therapy with pancreatic enzymes

Treatment
dependent on underlying etiology

Celiac Disease (Gluten

Enteropathy /Sprue)
Definition
abnormal small intestine mucosa due to intestinal reaction to gliadin, a component of gluten

Etiology
only autoimmune disease in which antigen (a.-gliadin) is recognized
associated with other autoimmune diseases, especially thyroid disease
gluten, a protein in cereal grains, broken down to gliadin, is toxic factor
HLA-DQ2 (chromosome 6) found in 80-90% of patients compared with 20% in general
population; also associated with HLA-DQ8

Epidemiology
more common in women
family history: 15% of first-degree relatives
may present any time from infancy (when cereals introduced) to elderly
peak presentation in infancy

Clinical Features
classically: diarrhea, weight loss, anemia, symptoms ofvitamin/mineral deficiency, failure to
thrive; now more commonly bloating, gas, iron deficiency
improves with gluten-free diet, deteriorates when gluten reintroduced
disease is usually most severe in proximal bowel
thus iron, calcium and folic acid deficiency more common than vitamin B deficiency
gluten enteropathy may be associated with dermatitis herpetiformis skin eruption, epilepsy,
myopathy, depression, paranoia, infertility, bone fractures/metabolic bone disease
12

 Investigations
small bowel mucosal biopsy (usually duodenum) is usually
diagnostic:
villous atrophy and crypt hyperplasia
increased number of plasma cells and lymphocytes in lamina
propria
increased intraepitheliallymphocytes
similar pathology in: small bowel overgrowth, Crohn's,
lymphoma, Giardia, HIV

consider CT enterography to visualize small bowel to rule out

lymphoma
evidence of malabsorption (localized or generalized)
Steatorrhea
low levels of ferritin/iron saturation, Ca2+ , Fe, albumin,
cholesterol, carotene, B12 absorption

improvement with a gluten-free diet; should not be started

before anti-tTG and biopsy
serological tests
serum anti-tTG antibody, IgA, is 90-98% sensitive, 94-97%
specific

 Treatment
Dietary counselling
gluten free diet: avoid barley, rye, wheat
oats allowed if not contaminated by other grains

rice and corn flour are acceptable

iron, folate supplementation (with supplementation of other vitamins as needed)

if disappointing response to diet, consider:

incorrect diagnosis
non-adherence to gluten-free diet
unsuspected concurrent disease (e.g. microscopic colitis, pancreatic insufficiency)
development ofintestinal (enteropathy-associated T-cell) lymphoma (abdominal pain,
weight loss, palpable mass)
development ofdiffuse intestinal ulceration, characterized by aberrant intraepithelial Tcell population (precursor to lymphoma)

Prognosis
associated with increased risk oflymphoma, carcinoma (e.g. small bowel and
colon)
risk of malignancy may be lowered by dietary gluten restriction

Gastroenteritis
Definition

Etiology

Gastroenteritis is an
inflammation of the
lining of the intestines
caused by a virus,
bacteria or parasites.

Virus
Bacteria
Parasites

urce: [Link]

Virus
The most common cause of gastroenteritis.
They infect enterocytes in the villous
epithelium of the small bowel.
The result is transudation of fluid and salts
into the intestinal lumen;
Sometimes, malabsorption of
carbohydrates worsens symptoms by
causing osmotic diarrhea.
Diarrhea is mostly watery.

Viruses
Four categories of viruses cause most gastroenteritis:
Rotavirus and norovirus cause the majority of viral
gastroenteritis, followed by astrovirus and enteric
adenovirus.
1. Rotavirus is the most common cause of sporadic,
severe, dehydrating diarrhea in young children (peak
incidence, 3 to 15 mo).
Rotavirus is highly contagious; most infections occur
by the fecal-oral route.
Adults may be infected after close contact with an
infected infant. The illness in adults is generally mild.
Incubation is 1 to 3 days.

Viruses
2. Norovirus most commonly infects older children and adults.
Infections occur year-round. Norovirus is the principal cause of
sporadic viral gastroenteritis in adults and of epidemic viral
gastroenteritis in all age groups; large waterborne and foodborne outbreaks occur. Person-to-person transmission also
occurs because the virus is highly contagious. Incubation is 24
to 48 h.
3. Astrovirus can infect people of all ages but usually infects
infants and young children. Infection is most common in
winter. Transmission is by the fecal-oral route. Incubation is 3
to 4 days.
4. Adenoviruses are the 4th most common cause of childhood
viral gastroenteritis. Infections occur year-round, with a slight
increase in summer. Children<2 yr are primarily affected.
Transmission is by the fecal-oral route. Incubation is 3 to 10
days.

Bacteria
Escherichia
this is a common
coli
problem for
travelers to
countries with poor
sanitation.
Infection is caused
by drinking
contaminated
water or eating
contaminated raw
fruits and
vegetables.

Campylobacter
the bacteria are found in animal
feces. Infection is caused by, for
example, consuming
contaminated food or water,
eating undercooked meat
(especially chicken), and not
washing your hands after
handling infected animals.
Azithromycin (500 mg orally one
time a day for 3 days) should be
first line Rx therapy for
symptoms lasting >7days,
otherwise self-limited
symptomatic therapy
recommended.

Salmonella
Bacteria are found in animal feces.
Infection is caused by consuming
food that is contaminated with
animal feces
8-48 hours incubation
Fever with chills
Nausea and vomiting
Cramping and abdominal pain
Diarrhea often grossly bloody 3-5
days
Tx if not self-limited:
Trimethoprim-sulfamethoxazole,
ampicillin, ciprofloxin

Shigella

Fever with chills

Abdominal cramps
Diarrhea often with blood and mucus
Headache, malaise
Direct person-to-person spread
Tx Trimethoprim-sulfamethoxazole,
ciprofloxin, levofloxacin, ampicillin
Increasing resistance to antibiotics
noted
Azithromycin, 500 mg orally on day
1 and 250 mg orally one time a day
for 4 days, may be an effective
alternative treatment for resistant
strains

Cholera

Clostridium difficile

History of travel to endemic

areas
Vibrio cholerae
Ingestion in contaminated food
Massive diarrhea-nonbloody,
liquid, gray, rice water
diarrhea, No odor
Dehydration occurs quickly
Vaccine available but short-lived
Tx with hydration and antibiotics

Clostridium difficile
20% chance after completing
broad spectrum antibiotic
The A and B toxins produced by
C. difficile can cause severe
diarrhea, pseudomembranous
colitis, or toxic megacolon.
High risk pts: nursing home
residents and employees,
hospitalized pts and employees
metronidazole (250 mg orally
four times a day or 500 mg
orally three times a day for 10
days)

Tetracycline, ampicillin,
azithromycin, trimethoprimsulfamethoxazole, fluoroquinolones

Parasites

Cryptosporidium
infection

Cryptosporidium
parvumcauses watery
diarrhea sometimes
accompanied by
abdominal cramps,
nausea, and vomiting.

Entamoeba

Entamoeba
histolytica(amebiasis)
is a common cause of
subacute bloody
diarrhea in the
developing world

Giardia
Giardia infection can be transmitted through water,
food, and person-to-person contact.
Watery yellow, sometimes foul-smelling diarrhea that
may alternate with soft, greasy stools, fatigue,
abdominal cramps and bloating, nausea, weight loss
Infections usually clear up within six weeks. But you
may have recurrent episodes or have intestinal
problems long after the parasites are gone.
Several drugs are generally effective against giardia
parasites, but not everyone responds to them.
Tinidazole 2 g orally as a single dose
Metronidazole (Flagyl) 250mg po tid x 5d

Noninfectious causes of diarrhea include

inflammatory bowel disease,
irritable bowel syndrome,
ischemic bowel disease,
partial small bowel obstruction,
pelvic abscess in the rectosigmoid area,
fecal impaction,
and the ingestion of poorly absorbable
sugars, such as lactulose and acute
alcohol ingestion.

Sign & Symptomps

Diagnose

Based on symptoms
Physical exam
The presence of
similar cases in your
Source:
community
[Link]
A rapid stool test
ses-conditions/viralSource:
[Link]
ng/MedImg/SIMS/GE2_1.html

gastroenteritis/basics/testsdiagnosis/con-20019350

Complication
Dehydration: the condition that
results from excessive loss of body
water (Dorland)

Source: [Link]

Source: [Link]

Prevention

rce: [Link]

Typhoid & Paratyphoid fever

Typhoid fever is a disease caused by
the bacteria Salmonella Typhi
Paratyphoid fever is caused by
Salmonella Paratyphi

Source: [Link]
file=pdf/76/[Link]&siteID=1&str_title=Typhoid%20and%20paratyphoid

Sign & Symptomps

Diagnose

Early symptoms includefever, general ill-feeling,

andabdominal pain. High fever(103F, or 39.5C)
or higherand severe diarrhea occur as the disease
gets worse.
Some people with typhoid fever develop a rash
called "rose spots," which are small red spots on
the abdomen and chest.
Abdominal tenderness
Agitation
Bloody stools
Chills
Confusion
Difficulty paying attention (attention deficit)
Delirium
Fluctuating mood
Hallucinations
Nosebleeds
Severe fatigue
Slow, sluggish,lethargicfeeling
Weakness

Acomplete blood count(CBC) will

show a high number of white blood
cells.
Ablood cultureduring the first week
of the fever can showS.
typhibacteria.
Other tests that can help diagnose
this condition include:
ELISAurine test to look for the
bacteria that cause Typhoid fever
Fluorescentantibodystudy to look for
substances that are specific to Typhoid
bacteria
Platelet count(platelet count may be
low)
Stool culture

Source: [Link]

Prognosis
Symptoms usually
improve in 2 to 4 weeks
with treatment. The
outcome is likely to be
good with early treatment,
but becomes poor if
complications develop.
Symptoms may return if
the treatment has not
completely cured the
infection.

Complications

Intestinal hemorrhage
(severeGI bleeding)
Intestinal perforation
Kidney failure
Peritonitis

Source: [Link]

Treatment

Prevention

Antibiotic therapy is the only

effective treatment for typhoid
fever.
Commonly prescribed
antibiotics

A vaccine is recommended for travel

outside of the U.S. to places where
there is typhoid fever. The Centers for
Disease Control and Prevention website
has information about where typhoid
fever is common. Ask your health care
provider if you should bring electrolyte
packets in case you get sick.
When traveling,drink only boiled or
bottled water and eat well-cooked food.
Water treatment, waste disposal, and
protecting the food supply from
contamination are important public
health measures. Carriers of typhoid
must not be allowed to work as food
handlers.

Ciprofloxacin (Cipro).In the

United States, doctors often
prescribe this for nonpregnant
adults.
Ceftriaxone (Rocephin).This
injectable antibiotic is an
alternative for people who may not
be candidates for ciprofloxacin,
such as children.

Source: [Link]