Introduction to internal medicine. Entry to gastroenterology. Prof. Hanych Taras, MD
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1 Introduction to internal medicine. Entry to gastroenterology. Prof. Hanych Taras, MD
2 Internal medicine of 4 th year (clinical therapy) one of the basic therapeutical disciplines studying laws of occurrence,course, diagnostics and treatment of digestive,bronchopulmonary, hematologic and endocrine diseases.
3 Digestive system А. Digestive tube: В. Large digestive glands: - Oral cavity; - Pharynx; -Esophagus; - Stomach; - Small intestine; - Large intestine; - Rectum. - Liver and gallbladder; - Pancreas
4 Basic functions of digestive system: 1. Secretory; 2. Мotor-evacuational; 3. Absorbing; 4. Excretory; 5. Іncretory; 6. Protective; 7. Receptor; 8. Hemopoietic.
5 Stomach functions: 1. Digestive functions: - Conditional; - Secretory; - Motor; - Absorbing. 2. Others : - Incretory; - Еxcretory; - Protective; - Hem(at)opoietic; - Receptor.
6 Liver functions: Меtabolic; Cholesecretory; Barrier; Hemopoietic (during embrionic period functionates as a blood-forming organ).
7 Complaints on digestive system pathology: 1. Local: - Ache; -gastric indigestion; -Intestinal indigestion; -defecation disorder; -dysphagia; -hematemesis; -melena, tarry motions. 2. General: - loss of appetite; -Weight loss; - Increased tiredness, reduced working ability; - irritability, sleep disturbance and other asthenoneurotic manifestations.
8 Complaints on liver and biliary system pathology: А. Hepatic ; Б. Extrahepatic ; В. Generally pathologic. А. Main hepatic complaints: 1. Pain in right hypochondrium; 2. Biliary (liver) dyspepsia: loss of appetite, hardness in right hypochondrium, bitter taste in mouth, belching, nausea, vomiting, bloating, diarrhea or constipation provoked by biliary excretion disorder. 3. Skin itch, sometimes with urticaria. 4. Jaundice, dark urine, decoloration of feces. 5. Мassive hematemesis.
9 Б. Main extrahepatic complaints: 1. Increased bleeding sickness (not only from esophageal veins); 2. Hormonal disorders (ОМC-disorder, decreased potency etc.); 3. Exhaustion,weight loss. В. Generally-pathologic complaints grouped in syndroms: - asthenoneurotic; -encephalopathic; - intoxicational ; -cholecysto-cardial; -arthritic; - hepatorenal etc.
10 Anxious symptoms (so- called red flags ) at digestive pathology. They indicate serious organic or acute pathology, necessity of urgent diagnostic measures, intensive monitoring and treatment, solution of the surgical intervention need issue.
11 : Anxious symptoms in gastroenterology: Acute pain, which lasts over 6 hours or increase; On background of abdominal pain dizziness, weakness, apathy, arterial hypotension, leukocytosis, ESR rising; Unmotivated dysphagy ; Repeated vomiting, hematemesis,; Visible bleeding, melena; Unmotivated fever, weight loss or anemia; Increasing enlargement of abdomen volume; Absence of passage of gases, peristaltic noises; Tension of the abdominal wall; Positive symptom of Blumberg's sign; Vertigo during defecation.
12 Gastroesophageal reflux disease
13 Gastroesophageal reflux disease (GERD) chronic recurrent illness,which appears with disturbing symptoms and/or inflammation of esophagus distal parts (reflux-esophagitis ) as a result of Gastroesophageal reflux regular stomach or/and duodenal content return to esophagus.
14 Clinical symptoms of reflux (GERD) heartburn, belching, regurgitation etc. disturbing symptoms symptoms of low intensity,which appear at least 2 days per week or middle/high intensity at least 1 day per week Clinical symptoms of reflux,which do not disturb a patient are not diagnosed as GERD
15 The main aggressive factor in development mechanism of GERD chronic gastroesophageal reflux of polyetiologic genesis.
16 Promoting factors of reflux and GERD development: Various diseases and syndroms:peptic ulcer, pancreatic diabetes, obesity, chronic constipations, meteorism syndrom, ascites of various genesis; pregnancy; smoking; chronic untreated cough;
17 Regular taking of medicines that reduce lower esophageal sphincter tone; hypodynamia ; junk food.
18 Character of esophagus mucous membrane local changes can vary: from absence of visual endoscopic changes to different stages of refluxesophagitis and its complications,e.g. Barrett esophagus or ulcer.
19 Barrett esophagus organic complication of reflux-esophagitis at GERD, characterized by intestinal metaplasia (changing of epithelium from stratified flat to cylindric) of mucous membrane of esofhagus distal part. It belongs to precarcenogenic conditions.
20 Barrett esophagus
21 GERD classification Uncomplicated GERD: -Non-erosive (without esophagitis)gerd among 60% of patients. -Erosive (with esophagitis)gerd among 40% of patients. There are no visible endoscopic changes in esophagus in the first case,but there are occurrences of reflux-esophagitis in the second.
22 GERD complications: 1. Esophageal stricture 2. Esophageal ulcer 3. Bleeding 4. Barrett esophagus 5. Esophageal adenocarcinoma
23 Clinical presentations of GERD There are esophageal (local) and extraesophageal presentations of GERD
24 І. Local presentations 1. Heartburn (observed in more than 80% of patients) 2. Acid eructation 3. Regurgitation 4. Chest pain (among 20% of patient) 5. Dysphagia (deglutitive problem ) or odynophagia (pain during passage of food through esophagus).
25 Heartburn features at GERD: Often occurrence; increase or occurrence during physical work,bending and horizontal position; Night occurrence;
26 ІІ. Extra-esophagus presentations Mostly happen at unerosive form of GERD (GERD without endoscopic visible esophagitis). 1. Oropharyngeal symptoms 2. Otolaryngological symptoms. 3. Respiratory symptoms 4. Cardial symptoms.
27 Criteria of GERD diagnostics: 1. Typical symptomatology 2. Endoscopy 3. Chromoendoscopy (for Barrett esophagus diagnosis clarification) 4. Gastric and esophageal fluoroscopy 5. Daily ph-metric- the main method of Gastroesophageal reflux diagnostics 7. Impendansometry 8. Manometry 9. Rabeprasol test 10.Histological research of biopsy material
28 General principles of GERD therapy (aim of treatment); maximal symptomatic relief; reflux-esophagitis healing; relapse and complication prevention.
29 Basic treatment procedures: Way of life correction. Drug therapy. Surgical treatment.
30 Gastric and duodenal ulcer
31 Ulcer is a complicated, pathological, mainly infectionally assotiated process, which appears as mucous membrane inflammation of gastroduodenal area with formation of local damage such as an ulcer (ulcers) - a result of disbalanse of protection and agression factors. Respectively, peptic ulcer (infectionally assotiated) inflammatory-ulcerative affection of stomach or/and duodenum, caused by cytotoxic strains of Helicobacter pylori.
32 Etiopathogenesis of ulcer disease (peptic ulcer) The main etiological factor of ulcer disease (peptic ulcer) is contamination of stomach mucous membrane by cytotoxic strains of Hp. Helicobacter pylori causes 95% of duodenal ulcers and 65-70% of stomach ulcers,according to international controlled researches. Helicobacter pylori Gram-negative,spiral-form bacterium, approximately 3 mcm long,0,5 mcm in diameter.it has 4-6 filaments and can move very fast even in thick gastric mucus,bile or nutritious environment like agar.
33 Непосредственное повреждающее действие на эпителиоциты Экспрессия факторов хемотаксиса Участие воспалительных клеток в повреждении эпителия слизистой оболочки Иммунный ответ организма J. Robin Warren and Barry Marshall
34 Other possible etiological (ulcerogenic) factors: Medicaments (UNSAID, hormones),other toxic agents; endocrine diseases (Zollinger Ellison syndrom, thyrotoxicosis, hyperparathyroidism); Distinct stresses ( including acute local hypoxia at МI, stroke, acute pancreatitis); Chronic local hypoxia (at cirrhosis-hepatohenic ulcers,at COPD, atherosclerosis) Other diseases (with local and systemic lymphoid tissue reaction):sarcoidosis, Kron disease etc.
35 Inclination for ulcers are genetically conditioned,as a rule, and can appear under influence of provoking factors.
36 Provoking factors: 1. Stresses. 2. Bad habits. 3. Alimentary factors irregular meals, overeating. 4. Decompensation.
37 Thank you for your attention!
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