Digestive System 2. Lecture 12. Pathology and Clinical Science 1 (BIOC211) Department of Bioscience. endeavour.edu.au

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1 Digestive System 2 Lecture 12 Pathology and Clinical Science 1 (BIOC211) Department of Bioscience Text Reference: Grossman, S.C. & Porth, C.M. (2014). Porth s Pathophysiology: concepts of altered health states, (9th ed.). Philadelphia, U.S.A. Walters Kluwer Health - Lippincott, Williams & Wilkins. endeavour.edu.au

2 Session Learning Outcomes o Understand the causation, clinical features, treatment aims and prognosis for the following conditions: o Disorders of Stomach. Gastritis Peptic Ulcer Disease o Disorders of the Small intestine Malabsorption, Coeliac disease Small bowel bacterial overgrowth, Short bowel syndrome Infections of the small intestine, Travellers diarrhoea, Giardiasis Endeavour College of Natural Health endeavour.edu.au 2

Inflammation of gastric mucosa, may be acute or chronic o Aetiology Acute - aspirin or NSAID therapy Chronic H Pylori 80%, viral - cyclomegalovirus & herpes simplex, autoimmune against parietal cells

4 Inflammation of gastric mucosa, may be acute or chronic o Aetiology Acute - aspirin or NSAID therapy Chronic H Pylori 80%, viral - cyclomegalovirus & herpes simplex, autoimmune against parietal cells o Clinical Features dyspepsia, nausea, vomiting, haematemesis, melaena o Treatment treat underlying cause GASTRITIS Endeavour College of Natural Health endeavour.edu.au 4

Small round ulcers penetrating to sub mucosa (muscularis) layer occurring in the oesophagus, stomach or duodenum o May be acute or chronic Acute - no fibrosis Chronic - shows fibrous base with

5 Small round ulcers penetrating to sub mucosa (muscularis) layer occurring in the oesophagus, stomach or duodenum o May be acute or chronic Acute - no fibrosis Chronic - shows fibrous base with presence of inflammatory cells acid and pepsin act on tissues (autodigestion) and ulcer may extend further into the deeper muscularis layer PEPTIC ULCER DISEASE Endeavour College of Natural Health endeavour.edu.au 5

o Duodenal more common in younger age group 5:1 to 2:1 male to female o Gastric 90% seen on lesser curve more common in older group 2:1 male to female o 10% of patients have both o Chronic ulcer show

6 o Duodenal more common in younger age group 5:1 to 2:1 male to female o Gastric 90% seen on lesser curve more common in older group 2:1 male to female o 10% of patients have both o Chronic ulcer show surface debris, neutrophil activity, granulation tissue and fibrosis (collagen) PEPTIC ULCER DISEASE Duodenal Ulcer Endeavour College of Natural Health endeavour.edu.au 6

Aetiology Helicobacter pylori found in 95% of duodenal ulcers 70% of gastric ulcers great percentage of ulcers NSAIDS - reduce pro inflammatory prostaglandins esp.

7 Aetiology Helicobacter pylori found in 95% of duodenal ulcers 70% of gastric ulcers great percentage of ulcers NSAIDS - reduce pro inflammatory prostaglandins esp. Cox 1 pathway hereditary - true genetic or familiar H pylori clusters Smoking Imbalance in acid pepsin versus mucosal resistance PEPTIC ULCER DISEASE Endeavour College of Natural Health endeavour.edu.au 7

8 PEPTIC ULCER DISEASE o Clinical Features o Epigastric pain or heartburn 30 minutes to 2-3 hours after meals hunger pain at night relieved by food or antacids o nausea, vomiting o weight loss o anaemia o occult blood in faeces o Investigations gastroscopy barium X-rays o Test for H Pylori breath test IgG antibodies stool test for immunoassay Endeavour College of Natural Health endeavour.edu.au 8

9 o Treatment H Pylori eradication Drug Therapy - triple therapy 2 anti-microbials H2 antagonist or proton pump inhibitors bismuth chelate may be added to anti-microbials reduction of risk factors e.g. smoking, alcohol surgery when complications arise partial gastrectomy vagotomy & pyloroplasty PEPTIC ULCER DISEASE o Complications Haemorrhage Perforation pyloric stenosis intestinal obstruction Endeavour College of Natural Health endeavour.edu.au 9

10 STOMACH CANCER Epidemiology Fourth most common cancer globally (2008) Half of the cases in Eastern Asia Less than 30% of cases in developed countries Aetiology Genetic factors Carcinogenic factors in the diet (e.g., N-nitoso compounds and benzopyrene found in smoked and preserved foods) Autoimmune gastritis Gastric adenomas or polyps Endeavour College of Natural Health endeavour.edu.au 10

11 STOMACH CANCER Pathogenesis Bacterial infection causes gastritis followed by atrophy, intestinal metaplasia and carcinoma. Indigestion Anorexia Weight loss Vague epigastric pain Vomiting Abdominal mass Clinical Features Endeavour College of Natural Health endeavour.edu.au 11

12 STOMACH CANCER Diagnosis Barrium x-ray studies Endoscopy with biopsy Cytologic studies Routine screening for persons with atrophic gastritis or gastric polyps Treatment Radical subtotal gastrectomy Irradiation for palliative care Chemotherapy for palliative care or metastatic spread Endeavour College of Natural Health endeavour.edu.au 12

STOMACH CANCER http://medicalpicturesinfo.

13 STOMACH CANCER Endeavour College of Natural Health endeavour.edu.au 13

14 OVERVIEW SMALL INTESTINE o Small bowel function Digestion and absorption of carbohydrates (CHO), protein, lipids, calcium, B12, Iron (Fe) o Small bowel disorder - clinical features diarrhoea, abdominal pain - site bloating weight loss nutritional deficiencies Endeavour College of Natural Health endeavour.edu.au 14

15 SMALL BOWEL INVESTIGATIONS o Blood FBE, proteins, calcium, B12 o Autoantibodies, endomysium, tissue transglutaminase, reticulin, gliadin o Barium follow through o Jejunal biopsy o 3 day fat collection (100 gm fat intake) o Lactose intolerance (intake of 50 gm lactose) Endeavour College of Natural Health endeavour.edu.au 15

16 MALABSORPTION Occurs as result of: o Deficiency of digestive enzymes o Mucosal malabsorption from damaged absorptive epithelium o Post mucosal lymphatic obstruction o Surgical removal due to disease Endeavour College of Natural Health endeavour.edu.au 16

17 COELIAC DISEASE Malabsorption syndrome - gluten sensitive, Enteropathy / intolerance Gluten present in wheat, barley rye and oats Incidence 1:1000 UK, 1:300 Ireland Females greater occurrence, often begins in 40 s May be latent/ undiagnosed in genetically susceptibility persons Familial tendency - 10% have 1st degree relative with disorder HLA antigens A1, B8, DR3, DR7, DQ2, DQ8 seen in many patients Often associated with other auto-immune disorders eg thyroid, diabetes, primary biliary cirrhosis, splenic atrophy, inflammatory bowel disease Proximal area most affected, less seen in ileum Endeavour College of Natural Health endeavour.edu.au 17

$COELIAC DISEASE (GLUTEN SENSITIVITY ENTEROPATHY) Pathophysiology Immune reaction to the Gliadin fraction -( gliadin) tissue transglutaminase, the autoantigens that produce anti endomysial antibodies$

18 COELIAC DISEASE (GLUTEN SENSITIVITY ENTEROPATHY) Pathophysiology Immune reaction to the Gliadin fraction -( gliadin) tissue transglutaminase, the autoantigens that produce anti endomysial antibodies Immune response destroys the intestinal villi (partial or subtotal villous atrophy) seen as flat mucosal surface hyperplasia of crypts chronic inflammatory cells in lamina propria Clinical Features Infants - steatorrhoea, weight loss Adults - bloating, abdominal pain, malaise, anaemia, weight loss, mouth ulcers, angular stomatitis Angular stomatitis omatitis-337.jpg Endeavour College of Natural Health endeavour.edu.au 18

19 o Investigations COELIAC DISEASE Tissue transglutaminase assay, anti endomysial antibodies, Full Blood Evaluation (FBE), Fe studies, Calcium levels small bowel follow through duodenal jejunal biopsy bone density o Treatment gluten free diet, replacement of nutrients pneumococcal vaccination (splenic atrophy) o Complications high risk enteropathic T cell lymphoma, small bowel cancers, head & neck squamous cell carcinoma Endeavour College of Natural Health endeavour.edu.au 19

COELIAC DISEASE Normal villi Atrophied villi in Coeliac Disease http://soulfoodheals.

20 COELIAC DISEASE Normal villi Atrophied villi in Coeliac Disease Endeavour College of Natural Health endeavour.edu.au 20

SMALL BOWEL BACTERIAL OVERGROWTH Increase count and changes of the normal flora bacterial colonies in small intestine o Aetiology caused by low gastric acid Impaired intestinal motility Structural

21 SMALL BOWEL BACTERIAL OVERGROWTH Increase count and changes of the normal flora bacterial colonies in small intestine o Aetiology caused by low gastric acid Impaired intestinal motility Structural abnormalities allowing movement of bacteria from colon upward Jejunal diverticulosis Diabetic diarrhoea Scleroderma Bacterial over growth Endeavour College of Natural Health endeavour.edu.au 21

22 SMALL BOWEL BACTERIAL OVERGROWTH o Clinical Features Diarrhoea watery Steatorrhoea B12 anaemia o Investigations Tests to exclude coeliac B12 & Folate assays Endoscopy - aspirated specimen for culture o Treatment Antimicrobials Endeavour College of Natural Health endeavour.edu.au 22

23 SHORT BOWEL SYNDROME Malabsorption picture from chronic small bowel disease or major small bowel resection. E.g. Crohn's, radiation enteritis, mesenteric infarction o Clinical Features Diarrhoea from non absorption of fluid Steatorrhoea Hypovolemia Weight loss Muscle loss o Treatment Positive fluid balance Dietary assessment and management for micro and macro nutrients Endeavour College of Natural Health endeavour.edu.au 23

24 INFECTIONS OF THE SMALL INTESTINE Infectious Diarrhoea o Major cause of morbidity and mortality esp. in young or elderly o Cause o Faecal oral spread of organisms including campylobacter, shigella, salmonella, with short incubation period o May cause secretory diarrhoea or mucosal inflammation and ulceration Investigation Stool cultures Treatment Fluid replacement Appropriate antidiarrhoeals and antibiotics Endeavour College of Natural Health endeavour.edu.au 24

INFECTIONS OF THE SMALL INTESTINE Giardiasis - Protozoal infection with Giardia intestinalis or G lamblia commonly found in contaminated water in tropical areas http://www.sciencephoto.

25 INFECTIONS OF THE SMALL INTESTINE Giardiasis - Protozoal infection with Giardia intestinalis or G lamblia commonly found in contaminated water in tropical areas Investigation 3 by stool cultures at 3 day intervals to identify the cysts Aspiration of fluid from endoscopic examination tested for cysts Treatment Tinidazole / metronidazole Endeavour College of Natural Health endeavour.edu.au 25

26 Readings and Resources Resources: o o Set Textbooks: Colledge, N.R., Walker, B.R. & Ralston S.H. (2014). Davidson s Principles and Practice of Medicine, (22nd ed.). Edinburgh. Churchill Livingstone. Grossman, S.C. & Porth, C.M. (2014). Porth s Pathophysiology: concepts of altered health states, (9th ed.). Philadelphia, U.S.A. Walters Kluwer Health - Lippincott, Williams & Wilkins. Additional textbooks: Davies, A. & Moores, C. (2010). The respiratory system: basic science and clinical conditions, (2 nd ed.). Edinburgh. Churchill, Livingstone, Elsevier. Field, M., Pollock, C., Harris, D. (2010). Systems of the Body: The Renal System; Basic Science and Clinical Conditions. (2 nd ed.). United Kingdom: Churchill Livingstone. Jamison, J.R. (2006) Differential Diagnosis for Primary Care: a handbook for health care practitioners. (2 nd ed.). Edinburgh. Churchill Livingstone. Lee, G. & Bishop, P. (2013). Microbiology and Infection Control for Health Professionals, (5th ed.). Frenchs Forest, NSW. Pearson Education. McCance, K.L. & Huether, S.E. (2014). Pathophysiology: the biological basis for disease in adults and children, (7 th ed.). St. Louis, MO. Elsevier. Murphy, K. (2011). Janeway s immunobiology, (8 th ed.). New York. Garland Science. Noble, A., Johnson, R. & Bass, P. (2010). The cardiovascular system: basic science and clinical conditions, (2 nd ed.). Edinburgh. Churchill, Livingstone, Elsevier. Pagana, K.D. & Pagana, T.J. (2013). Mosby s diagnostic and laboratory test reference, (11 th ed.). St. Louis, MO. Elsevier. Smith, M.E. & Morton, D.G. (2010). The digestive system: basic science and clinical conditions, (2 nd ed.). Edinburgh. Churchill, Livingstone, Elsevier. VanMeter, K.C. & Hubert, R. (2014). Gould s pathophysiology for health professions, (5 th ed.). St. Louis, MO. Elsevier. Endeavour College of Natural Health endeavour.edu.au 26

27 COMMONWEALTH OF AUSTRALIA Copyright Regulations 1969 WARNING This material has been reproduced and communicated to you by or on behalf of the Endeavour College of Natural Health pursuant to Part VB of the Copyright Act 1968 (the Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice. Endeavour College of Natural Health endeavour.edu.au 27

Neoplasia 2. Lecture 9. Pathology and Clinical Science 1 (BIOC211) Department of Bioscience. endeavour.edu.au

Neoplasia 2. Lecture 9. Pathology and Clinical Science 1 (BIOC211) Department of Bioscience. endeavour.edu.au Neoplasia 2 Lecture 9 Pathology and Clinical Science 1 (BIOC211) Department of Bioscience Text Reference: Grossman, S.C. & Porth, C.M. (2014). Porth s Pathophysiology: concepts of altered health states,