25 The Digestive System Objectives In this chapter we will study ‘+ some syimptoms of digestive system disorders; ‘+ diagnostic techniques specific forthe digestive system; © pancreatitis, oot liver disorders hepatitis and cirrhosis, + three common inflammatory bowel disenses—auleerative colitis, Crohn disease, and diverticulitis; » appendicitis; and + colorectal cancer Assessment of the Digestive System ‘This chapter discusses the techniques spplied in diagnosing digestive system disorders and then goes (to describe some structural and functional discases involving the digestive system. Disorders related to rutrition and metabolism are discussed in chapter 26, Common Symptoms of Digestive System Disorders Patients with disorders of the digestive system most commonly complain of such symptoms as. pain, nausea, dyspepsia (indigestion), wunorexia (loss of appeit), and dysphagia (difficulty swallowing). ‘These syinptoms an indieate disorders of othor body systems a5 well, 60 it is necessary to take a carefil patient history to determine whether the problem is digestive in nature, Helpfil questions include, “When did you frst notice the pain?” “Where do you feel the pain?” and “What makes the pain batter (or worse)?” For example, a patient complaining of dyspepsia localized 0 the epigastric region and allevnied by eating may have an ulcer, whilo a patient experiencing Abdominal pain in the right lower quadrant that is not alleviated by cating may have appendicitis Physical Examination Examination of the digestive system involves observation, palpation, percussion, and auscultation, For example, if a patient complains of anorexia ani dysphagia, the clinician may look into the oral cavity for lesions or bleeding gums. If the clinician notes jaundice (yellowish skin, corneas, mucous membranes, and body fluids), he of she may have uncovered a cluo to liver disease or gallbladder obstruction, A distended abdomen could indicate anything from obesity or pregnancy to ascites or ccancer. Striae (stretch marks) may suggest elema, Cashing disease, or ascites. Palpating the abdomen enables the clinician to ‘evaluate the size, shape, and texture of an organ, Intestinal peristalsis can be felt in nonobese patients, ‘and abnormal peristaltic waves can indicate certain diseases. In. many liver diseases, the liver becomes larger and firmer than noemal. Palpation also allows the clinician to determine whether the abdominal muscles are excessively contracted or relaxed, In some diseases, a patient experiencing abdominal pain may contract the abdominal muscles to “protect” the region; this is known as abdominal guarding, In auikition, some patients present with rebound tenderness whereby they do not experience excessive pain upon palpation but report sudden pain when the ‘examniner’s fingers are removed. Using palpation, the clinician may also be able to pinpoint the spectfic areas that are painful to help determine precisely which organ is involved as well as to check for abdominal masses, herniation of the abdominal wall or distension of the abomen, ‘Although percussion is routinely used to evaluate the respiratory system, it is less helpfl in examining ‘the gastrointestinal (GI) tract. There is normally litle air in the GI tract tp carry sound waves. However, percussion is useful in abdominal examinations t@ ‘detect abnormalities of the liver and gpleen and fuid ‘and gas avcumulation in the abdominal cavity or lower GI tract, 149Auscultation is very useful in determining. the peristaltic actions of the GI tract. Contractions of the smooth muscle of the tract produce characteristic bowel sounds—normally 5 to 30 clicks or gurgles por ‘minute. Prolonged gurgling (a “growling stomach”) is called borborygmus. ‘The frequency of the bowel sounds is retticed by intestinal obstruction and increased in diarrhea, Laboratory Procedures Following physical examination, various laboratory procedures can narrow dovm a diagnosis. For ‘example, some liver disorders cause increased levels ‘of hepatic enzymes in the blood serum (aspartate transamimse, alanine transaminase, alkaline Pinosphatase), reduce the concentrations of plasma protein, or increase the prothrombin time or clotting time. An increase in biliubin may suggest liver oF gallbladder disease Analysis of the feces (too!) also. provides diagnostic information, The presence of blood suggests inflammation, uleraton, o cancer inthe GI tract, When blood is present in quantities too smal to be visible, i is called occult blood. Occult blood can nevertheless be detected by. ehetival tests, Steatorrhea (fatty fees) indicates panereatic dscaso, cyte fibrosis, or a disordor affecting absorption I is normal for the feces to contain certain becteria, such 48 F. col. infection is suspected, however, tho stool sample may be. examined for parasites (such as amcbae, tapeworms, or rourdworms) or thir gas, cultured for bacterial identification. Safmonella, Campylobacter, or Shigella is commonly found in cases of acute darrhen, Finally, atibodis to hepatitis and other viruses and antigens diagnostic of colorectal cancer ean also be detected in sto! sample, Imaging Techniques ‘The digestive system ean be examined by MRL, CT, and X ray (radiography). Radiograpy of the Gi tract tusos a contrast medium, such as barium, to. make structures more visible, A barn swallow is use for visualization of the esophagus, stomach, and duodenum, and a barinnr enema for visualization of the colon, Siafography is radiography of the salivary lands; choleeystography is radiography of the gallbladder; and cholangiography’ is radiography of the bile dct. As mentioned in. chapter 2 of this manu, endoscopy employs a flexible tube (endoscope) with « 150 small fiber-optic camera to view interior spaces in tho body, Its uses specific to the digestive system include -gasiroscopy, endoscopic examination of the stomach: esophagogastraduodenascopy, examination of th tract from esophagus. to duodenum; colonaseery, ‘examination ofthe large intestine; and sigmoldoseopy, examination of the rectum and sigmoid colon, In addition to providing a visual image, endoscopes can be equipped to obtain fluid or tissue samples for study. Pancreatitis Pancreatitis is inflammation of the pancreas. deule poncreatiis is a severe inflarmtion requiring hospital care, but itis short-lived and leaves no ating damage; chronic. pancreatitis, by contrast, lists longer and keves the pancreas permanently damaged ‘Most people who develop pancreatitis are problem rinkors, but it can also be triggered by bile duct cbstrucion, infection, trauma, surgery, and other causes. The underlying mechanism is thought 1 be damage to the pancreatic weini and duets, allowing potent pancreatic digestive enzymes to leak and digest the pancreati tissue. As these enzymes invade the bioodstream, they damage the blood vessels and cause a Jos of fui into the tissues, thus presenting a tet of kypovolemia, circulatory shock, and veal flr. ‘A person’ with either form of pancreas experiences sudden epigastrc and midabominal pai, nausea, vomiting, sweating, fever, and tachycardia EBloyated levels of amylse and other serum enzymes, along with other omatologic signs, point to Pavereetitis but are not specific enough to confirm this disease. A CT scan can aid diagnosis by revealing bile tract obsiruction or pancreatic edema, and can also help reveal the extent of pancrestic damage Pancreatitis that progresses.to the-point of necrosis and hermosthage has @ mortality rato of 10% to S0% Treatment focuses on stopping the autodigeton of the pancreas, rdlieving the pain with narcotics, restoring blow volume, and withholding foe (but giving parenteral hyperalimentaton) in order to rest” the pancreas and minimize the secretion of its enzymes, Liver Disorders: Hepatitis and Cirrhosis Disorders of the liver produce extremely serious complications, including jaundion, portalhypertension, epetic encephalopathy, und ascites. ‘Two common hepatic disorders are hepatitis and cirhosis, Hepatitis, inflammation of the liver, is associated chiefly with viruses called the hepatitis 4, B, C, D, and E viruses, abbrevisted HAV, HBV, etc. It can also result from alcohol abuse, certain drugs, and ‘other diseases, but only viral hepatitis is discussed here, ‘The viral strains causing hepatitis differ in the following respects: © transmis ough food or water Contaminated! with feces, parenteral means such as blood transfusion and contaminated needles, and sexual transmission; + prophylaxis (prevention) —by vaccination, water purification, hygiene, and blood sereening, onset of symptoms—scute (abrupt) or insidious (gradual); + severity—for example, HAV produces mild symptoms, while the symptoms of other typos are more severe, with HEV especially so in pregnant ‘women; and + affected age groups—that is, HAV and HEV affect especially children ane! young adulls, and the others affect alt ages HAY produces a mild infection and is very common, About 45% of people in urban areas show evidence (serum antibodies) of having had it. HAV spreeds rapidly in settings such a8 day-care centers and institutions for mental patients. afection is followed by long-lasting immunity, HBV. ig transmitted sexually and through blood andl other body fluids. HCY i responsible for most post-transfusion hepatitis, but is becoming increasingly common as a sexually transmitted disease (already more prevalent than AIDS). HDV occurs only in people with HBV, because it depends on HBV for its own replication, HEV js commonly spread through contaminated drinking water in developing countries, The disease progresses through three phases: prodremal, icteric, and recovery. ‘The prodromal phase begins about 2 weeks alter exposure and lasts 1 to 2 weeks. Signs and symptoms include fatigue, ‘malaise, nausea and vomiting, and pain in the right upper quadrant of the abdomen. A person miay’ become nauseated by the odor of food, ancl changes in the sense of taste inhibit the desire for tobacco or alcohol. A weight loss of 2 to 4 kg (4-9 Ib) is ‘common, ‘The transition from the prodromal to the ieterie phase is marked by the appearance of jaundice. This phase lasts for the next 2 to 6 weeks. Teterus (Gaundice) results from cellolar destruction in the liver and the blockage of bile secretion, causing bile pigments to accumulate. Bile pigments are responsible for the brown color of feces, Consequently, the feces in an icteric patient are often gray or clay-coloced, ‘whereas the urine Is abnormally dark. ‘The liver is ‘enlarged and tender, and signs of liver dysfunetion ‘appear, such as a rise in serum enzyines (aspartate ‘transaminase and alanine transaminase) and prolonged blood clotting ‘The recovery phase begins when the jaundice iseppears and usually lasts 6 to 8 weeks, The symptoms diminish and liver functions return to rpormal, In HBV and HCY infection, however, chronic hepatitis may follow and last up to 6 months. Chronic hepatitis isn risk factor for cirthesis and liver cance, and FICY is the leading cause of liver Caihure andthe reed for liver transplants Hepatitis is diagnosed from the paticat history, signs and symptoms, elevated serum enzyme levels, and detection of the hepatitis antigens. There is. no specific treatment for acute hepatitis except t0 rest, eat a Jow-let, high-carbobydrate diet, and wait for recovery. Interferon is sometimes useful in treating chronic hepatitis. Health-care providers can procect themselves from hepatitis by vaccination, avoiding contact with patients’ blood and body fluids, and ‘wearing gloves, especially if changing bedpans or being otherwise exposed to patients’ wastes, Cirrhosis is an irreversible inflammatory liver disease. It develops slowly over a period of years, but has a high rate of mortality, ranking as one of the leading causes of death in the United States. Cirrhosis js characterized by a disorganized liver histology’ in hich regions of sear tissue alternate with irregular noxivies of regenerating calls, giving the liver « hunpy or knobby appearance and a hardened texture, The bile passages become obstructed, leading to jaundice, Obstruction of the hopatic circulation stinwlates angiogenesis, the growth of new blood vessels to bypass the congested liver, As blood bypasses the liver, the condition of the liver grows worse, with farther necrosis and often, liver failure. The most common form of cirrhosis is aleoholie cirrhosis, 151Another type, biliary efrrhosis, has a primary form that has no known cause (possibly autoimmune) and a secondary form that stems from gallstones, chronic pancreatitis, or other conditions that obstruct the bile passages. A third type, postnecrotic cirrhosis, often follows chronic hepatitis C and other liver diseases, Citthosis has several of the same signs as hepatitis jaundice, pain, anorexia, Weight loss, slovated hepatic enzymes in the blood serum, and reduced liver function (prolonged blood clotting and fow blood albumin levels), Diagnosis is basod on the patient history, risk factors, physical examination, hematology, and sometimes liver biopsy, The damage js imeversible, and the prognosis. i offen poor. However, treatment is possible and includes rutvitionl support, rest, contro! of gastrointestinal bleeding and ascites, avoidance of causative agents such as alcohol, use of immunosuppressive and anti- inflammatory drugs, and sometimes a liver transplant, Inflammatory Bowel Diseases Inflammatory bowel diseases are usually chronic and ‘may affect the small intestine, the large intestine, or both. The three most eommon are ulcerative colitis, Crohn disease, and diverticulitis. Ulcerative colitis is a chronic inflammatory disease of the large intestine, especially the rectum and sigmoid colon. It usually strikes between the ages of 20 and 40, The cause is unknown, but heredity one tisk fictor since the condition’ is. particularly ‘common among people of Jewish descent, is more common among whites in genoral than among othor groups, and occurs in identical twins more often than) in nontwin siblings. The colonic mucosa becomes dat red, velvety, and swollen, Small lesions begin in the inestinal crypts and coalesce to form larger uleers. ‘The disease progresses. to painful cramps, watery sfiarthea, and the urgent need t0 defecate, In sovere cases, a patient may have as many as 10 or 20 watery, bloody bowel movements per day. Kdema and constriction of the colon can cause intestinal obstruction, and in some cases perforation, hypotension, and shock may oecur. Uleerative colitis is diagnosed by pationt history, physical examination, hematology, sigmoidoscopy, and barium-enema X ray. It is treated with anti-inflammatory and antibiotic rugs, LV. fluid replacement, and sometimes colostomy or surgical resection of the inflamed region, 152 Crohn disease is similar to ulcerative colitis in pathology, and the two are sometimes difficult to differentiate. Crohn disease, however, alfects both the Jarge and sinall intestines and seldom involves the rectum. The ileocecal region is the mast commonly affected. The (wo diseases are similar in risk factors and etiology. Crohn disease produces fissures that ‘ross the intestinal wall and may involve both mucosa and serosa. ‘These fissures and the areas of ede between them give the intestinal wall a cobblestone appearance, The chief symptom is an. “irritable bowel” that may last for several years, producing diarrhea, abdominal tendemess or pain, and weight Joss, Malnutrition may result from malabsorption of vitamin By, vitamin D, and calcium, Crohn disease ‘may be treated with immunosuppressive drugs and, if necessary, with surgery for resulting obstructions, abscesses, cr fistulae (abnormal passages) Diverticulitis is the inflammation of divertioula saclike herniations of the mucosa of the colon through the muscular wall. It is most common in eklerly poopie in developed countries where the diet has a high proportion of refined foods and a low ber ‘content. The most commonly affected region of the Gl tract is the sigmoid colon. The condition is worsened by lov-fiber diets because the lack of bulk in the stool reduces the diameter of the colen, increasing both the pressure in the humen and the’ risk of herniation, Diverticulitis causes painful cramping, diarrhea or ‘constipation, and flatulence, Occasionally, a diverticulum ruptures, and peritonits (inflammation ‘of the peritoneum) may ensue, Divorticultis_is diagnosed in the same way as uleerative colitis, ‘The symptoms are sometimes relieved by increasing the amount of fiber in the diet, but severe cases can require surgical resection Appendicitis Appendicitis. is inflammation of the yermiform appendix. Tt accurs in 7% to 10% of the population and most often strikes between the ages of 20 and 30. ‘The cause of appendicitis is still uncortain, The most popular theory i that it begins with obstruction ofthe appendix by compacted feces, a tumor, or a foreign body that a person has swallowed, ‘The obstruction blocks drainage of the appendix, so fluid accumulates, pressure increases, and the compression of blood ‘vessels in the appendix leads to hypoxia, nectoss, and ulceration, This progresses to bacterial invasion, thrombosis, gangrene, and sometimes perforation. Ifthe appendix is perforated, the spread of bacteria into the peritoneal cavity causes peritonitis. ‘The signs of appendicitis begin with a vague pain in the epigastric or umbilical region. The pain becomes more intense over the next 3 t0 4 hours, then, may subside and return later in @ new location, the right lower quadrant (RLLQ) of the abdamnen, The pein is nccompanied by fever, nausea, and vomiting Physical examination typically shows rebound tenderness in the RQ; hematologic work shows both the neutrophil count and totai WBC count to be clevated; and the appendicitis may be confirmed by ultrasound, 2 CT scan, or laparoscopy (viewing the abdominal cavity with an endoscope inserted through 2 small umbilical incision). ‘The treatment is appendectomy, the mest ‘common emergency surgery of the abdomen. Major appendectomy scars are now largely a thing of the past since laperoscopie surgery allows the procedure to be performed through just three small incisions, one ‘of which is concealed in the umbilicus. Appendectoriy is offen performed even upon suspician of appendicitis ‘because itis too risky to walt. However, because of this, about one appendicitis surgery in six shows the appendix to be healthy, leaving the :rue source of the pain still to be identified. In this event, surgeons examine the ileocecal area for signs of inflammatory bowel disease and examine female paticats for ovarian cysts, salpingitis (inflammation of the uterine tubes), ‘or ectopic pregnancy (iexplantation of an embryo in the uterine tube) Colorectal Cancer Colorectal cancer (cancer of the lower intestinal tract) causes 10% to 15% of all cancer-related desths annually in the United Stetes, Worldwide, is incidence is increasing, especially in populations Where the diet tends to be low in flber and high in animal protein, fat, and refined carbohydrates, Aside from die, the risk factors for colorectal eancer include aging (most cases occur after age 50, with peal incidence between the ages of 6 and 75), iverticulitis, chronic ulcerative colitis, and a family history of colorectal cancer. The development of colorectal cancer bas been linked to mutations in tumor suppressor genes called p53, APC, and DCC and activation of the ras oncogene, Patients in the early stazes of coforcetal cancer do fot usualy exhibit specific signs and symptoms and are therefore less likely to seek help right away, The patient may complain of lower abdominal pain and rectal bleeding. One of the best diagnostic tools is an ‘cecult blood test, in which small fecal sample is spread on a card with a chemical reagent that will disclose the presence of even invisible quantities of blood, [f colorectal cancer is suspected, imag confirm the diagnosis, ‘Treatment consists of surgically removing the ‘cancerous region and —associnted lymphatic ‘components. Radiation therapy may be used prior to surgery to deereass the size of the tumor. Following surgery, chemotherapy and immunotherapy may be cmployed to treat metastasized tumors and limit the securrence of the cancer. The 5-year survival rate following surgery is greater than 90% for cancer limited to the mucosa, As metastasis increases, survival rates decrease proportionately.