Gastroenterology

lecture II-2
Irritable Bowel Syndrome
Malabsorbtion Syndrom
Inflammation Bowel Disease

Clinical anatomy and physiology of small and large

intestine
Functions:
digestion
absorption
excretion
motility

Stomach

Calcium
Magnesium
Iron
Monosaccharides

Bile
Pancreatic enzymes
Oil-soluble vitamins

Small intestine

Water-soluble
vitamins

Fatty acids
Bile acids

Vitamin B12
Electrolytes

Amino acids

Large
intestine

Wather

Serotonin is the main neuromediator that regulates the

gut activity
Visceral sensytivity
- Serotonin
- Calcitonin
- Neurokinin A
- Enkephalin
Secretion
- Serotonin
- Acetylcholine

Motility
- Serotonin
- Acetylcholine
- Nitric oxide
- Substance C
- Vasoactive intestinal peptide
- Cholecystokinin

Cardinal symptoms of lower part of gastrointestinal tract

disorders
Symptoms
Diarrhea
Constipation
Anorexia
Weight loss
Abdominal pain
Bloating
Meteorism

Syndromes
Syndrome of intestinal
dyspepsia
Maldigestion
syndrome
Malabsorbtion
syndrome
Bleeding from lower
part of GI tract
Acute abdomen
Irritable bowl
syndrome

Diseases
Celiacia
Whipples disease
Lactase insufficiency
Inflammatory bowl
diseases:
Crones disease
Ulcerative colitis

Diarrhea
1. Transit of soft stools with a lot of fluid
2. > 3 times per day
3. Imperative demand of defecation

Diarrhea
small intestine

Without blood or mucus

Without tenesmus
Polyfecalia but not very frequent

large intestine

A touch of blood or mucus

Tenesmus
Stool is frequent but with
small portions

Diarrhea: types, etiology, pathogenesis

Acute (up to 1-2 weeks)
Food poisoning (due for microbs or not)
Bacterial infections: E.coli, Shigella,
Salmonella, Campylobacter, Yersinia
Viral infections: Rotavirus
Protozoan infections: Entamoeba,
Giardia lamblia
Drugs:
antibiotics (l.deficile)
laxatives
antacids (Mg)
anticholinesterase drugs
colchicin
preparations with Au
quinidine
cardiac glycosides

Chronic (> 4 weeks)

Osmotic diarrhea (osmotic laxatives
and lactose)
Secretory diarrhea (bacterial toxins,
hormones, fatty and bile acids,
laxatives)
Inflammatory diarrhea (infections,
inflammatory bowl diseases,
celiacia, lymphoma, iscemia)
Hypermotoric diarrhea (irritated
bowl syndrome)

Diagnosis of diarrhea
If chronic full investigation in every case
Acute investigation is indicated if there are signs of anxiety or
special anamnesis' data
Plan of investigation depend on anamnesis data

Signs of anxiety
Symptoms >48 hours
Severe pain
Body temperature >38,9
Blood or helminthes in stool
Signs of dehydration (dry mouth, thirst, reduction of skin turgor,
oligo- or anuria, vertigo)

Principles of treatment of diarrhea

Elimination of the cause
Correction of water and electrolytes disorders
In some cases - antidiarrheal agents

Diagnostic criteria of constipation

1) 2 or more of criteria listed below:
1. Straining efforts in course of defecation at least in 25% of
defecations
2. Solid stool at least in 25% of defecations
3. Feeling of incomplete evacuation at least in 25% of defecations
4. Feeling of anorectal obstruction at least in 25% of defecations
5. Need in hand manipulation to facilitate the defecation at least in
25% of defecations
6. Less than 3 defecations per week
2) Liquid [watery] stool without laxatives a very rare event

Malabsorbtion syndrome

Maldigestion syndrome insufficiency of

digestion

Maldigestion impaired digestion of food

Cause enzymes deficiency (congenital or acquired)
It may be due to impairment of:
luminal digestion,
membrane digestion,
intracellular digestion,
mixed forms
Clinical manifestation: diarrhea, meteorism, other dyspeptic
disorders
It is a component of malabsorption syndrome

Malabsorption syndrome: key points

Malabsorption - disorder of absorption of one or more nutritive
materials in small intestine with impairment of metabolic processes
There are congenital and acquired forms
Intestinal manifestations: diarrhea, polyfecalia, steatorrhea,
creatorrhea, amylorrhea
Malabsorption syndrome affects the metabolism of proteins,
carbohydrates, fat, vitamins, minerals, water and electrolytes

Malabsorption syndrome: causes

Enterogenic

enteritis, Crones disease, infections, parasites,

ischemia
Gastrogenic peptic ulcer, gastritis, cancer
Pancreatogenic pancreatitis, mucoviscidosis, tumors
Hepatogenic acute and chronic liver diseases
Postresection state
Endocrinogenic DM, disthyreosis
Drugs
Radiation

Pathogenic factors
enzimopathy
damage of specific transport mechanisms
immunologic disorders
small intestine bacterial overgrowth
motility abnormalities
morphologic changes of mucose

ASSESTMENT OF THE NUTRITIONAL STATE

Gross malnutrition is usually easy to recognize
Lesser degrees may be difficult to detect, particularly if oedema
is present
Malnutrition may be due to starvation, to maldigestion of food
or to malabsorption

WAYS TO ASSESS THE NUTRITIONAL STATE

The clinical history
The physical examination
More subtle indices of malnutrition include muscle function
tests and evaluation of creatinine excretion and levels of albumin,
hemoglobin, ferritin and iron-binding capacity, prothrombin time

Diagnosis of malabsorption
Blood tests detection of nutrients deficiency
albumin, cholesterol, iron, calcium, magnesium, vitamin A, folic acid
Stool tests
steatorrhea, creatorrhea, amylorrhea, <6,0
big fecal mass (>500 g/day),
amount of fat in stool >6 g/day
Assessment of absorption function with specific tests
absorption test with D-xilose
Schilling test

Instrumental methods
X-ray investigation of small intestine
abdominal ultrasound
endoscopy of small intestine with biopsy

Treatment of malabsorption syndrome

1. Treatment of basic disease

2. Correction of absorption disorders:

Diet with high protein and low fat intake or special

nutrition

Replacement therapy with vitamins A, D, , , 12, folic

acid and iron preparations

enzymes

In case of increased peristalsis loperamid, in sever

cases - octreotid

binding and enveloping (smekta and other)

Celiac disease (gluten enteropathy): key points

Genetic disease- deficiency of peptidase that hydrolise the protein gluten
of cereals (wheat, rye, and barley)
Accumulation of gluten and gliadin autoimmune inflamation death
of villi and damage of intestine mucosa
Clinical picture: malabsorption. Commonly minimal signs: osteoporosis,
anemia without gastrointestinal manifestations
Diagnosis:
biopsy of small intestine
serological tests: antibodies to gliadin, endomiosin, reticulin
Treatment: aglutenic diet, in sever cases - glucocorticoides

Celiac disease
biopsy of small intestine
normal

pathology

Whipples disease
First described in 1907
Etiology: Tropheryma Whipplei [trophi (nutrition) eryma (barier)], first successful
culture was received in 2000.
Prevalence: a rare disease, male:female8:1, mean age 50
Clinical manifestations: malabsorption syndrome, diarrhea, weight loss, fever, arthritis
and arthralgias, cardiac involvment
Diagnosis: biopsy of small intestine. Specific sign infiltration of mucosa with big
macrophages with SHIK-positive granules. In the cells - T. Whipplei.
Treatment: antibiotics

Whipples disease

Functional bowl disorders

Functional meteorism
Functional constipation
Functional diarrhea
Irritable bowl syndrome
Undifferentiated functional bowl disorders

Irritable Bowel
Syndrome

Irritable bowel syndrome

IBS has probably existed for a long time and under many
names.
There is increasing awareness of its importance in the
community, family practice, and gastroenterology.
IBS is not a disorder defined by an unequivocal
pathophysiology or a uniform clinical presentation.
The definition of IBS is based on the clinician recognizing
a frequently occurring symptom cluster.
The general acceptance of that cluster has been formalized
in consensus conferences, creating the regulary updated
'Rome criteria'.

Irritable Bowl syndrome

Prevalence
15% of adult population
Etiology not clear
Visceral hypersensitivity
Motility disorder
Neurotransmitter inbalance
Infection
Psychosocial factors

Visceral Sensitivity in IBS

Pain
Dorsal root ganglion

Brain stem

Spinal
cord

Ascending pain pathway

Viscera

Diagnostic criteria of IBS

Rome criteria III (2006 .)
Recurrent abdominal pains or discomfort:
3 days per month 3 previous months

+
Any 2 or more of down listed criteria:
Relief after defecation; and/or
Start is associated with changed frequency of stool; and/or
Start is associated with changed consistency of stool
* Presence of named criteria during last 3 months, if first
manifestation appeared 6 months before diagnosis

Clinical variants of IBS

pain syndrome + diarrhea
pain syndrome + constipation
pain syndrome + diarrhea / constipation

Diarrhea &
pain

Diarrhea,
constipation &
pain

Constipation
&
pain

IBS: clinical manifestations

Abdominal pain and discomfort
usually not localized, variable
Change of frequency and/or
character of stool
bloating
urgency
feeling of incomplete evacuation
mucous in the stool

chest pain, headache

heartburn
nausea or dyspepsia
difficult swallowing
sensation of a lump in the throat

Red Flags
Additional diagnostic screening needed
for atypical presentations such as:
Anemia
Fever
Persistent diarrhea
Rectal bleeding
Severe constipation
Weight loss

Nocturnal symptoms of
pain
and abnormal bowel
function
Family history of GI
cancer, inflammatory
bowel disease,
or celiac disease
New onset of symptoms in
patients 50+ years of age

Differential Diagnosis

Inflammatory bowel disease

Infection (Giardia lamblia )
Peptic ulcer disease
Motility disorders
Chronic pancreatitis
Malabsorption/Bacterial
Overgrowth
Gynecological disorders

Management of IBS
Positive diagnosis of the syndrome, exclusion of organic disorders
Life style modification
fibers consumption, change of nutrition character, assessment of patients
psychological status
Symptomatic therapy

Antagonists/agonists of
serotoninergic receptors

Alternative therapy

Anti-diarrheals

Alosetron (Lotronecs)
(in case of diarrhea)

Hypnotherapy

Laxatives

Tegaserod (Zelnorm)
(in case of constipation)

Holistic therapy

Antispasmodics
Aciolitics
Antidepressants

Correction cognitive
changes

Inflammatory bowel disease

(IBD)

A general term for a group of chronic inflammatory disorders of unknown cause

involving the gastrointestinal tract.

may be divided into two major groups

chronic nonspecific ulcerative colitis (UC)
Crohn's disease (CD)

While the occurrence of both diseases peaks between the ages of 15

and 35, they have been reported from every decade of life.
While the causes of UC and CD remain unknown, certain features of
these diseases have suggested several areas of possible importance.
These include familial or genetic, infectious, immunologic, and
psychological factors

Inflammatory bowel disease

Nonspecific ulcerative
colitis (UC)
Crohns disease (CD)

Crohns disease

Nonspecific ulcerative colitis

Colitis of unknown etiology

Crohns disease

Pathogenesis
Nonspecific ulcerative colitis

Etiology is unknown
Genetic and immunological factors lead to abnormalities in
recognizing auto antigens in GIT

Crohns disease

Ulcerative colitis
Localization of
damage

Volume of
damage
Depth of damage

Ulcerative colitis
Chronic diffuse inflammation of large intestine with edema and
superficial ulceration of mucosa
Starts always from damage of rectum, and than the process involves
other parts of large intestine
Symptoms:

rectal bleeding, fever, diarrhea, abdominal pain,

moderate anemia.

Complications:
Toxic megacolon (dilation of the gut with
thinning of gut wall, high risk of perforation)
Large intestine carcinoma (constant
regeneration of epithelium---> displasia).

Crohns disease

Chronic granulematose (in some cases transmural) inflammation of the gut wall
of unknown origin
Damage may be localized in any part of GIT from oral cavity up to anus,
damaged areas, crypt abscesses
45%: terminal ilea involvement and larg intestine
33%: small intestine
25%: large intestine

Symptoms: abdominal pain, diarrhea, fever

Complications:
Strictures, fistulas
Perforation
Gall bladder stones (abnormalities of
bile acids absorption)
Hydronephrosis (adhesion of ureter
to stricture)
Adenocarcinoma of large intestine,
anal zone)

Extraintestinal manifestations of inflammatory

diseases of intestine

Differential diagnosis of IBD

CD

UC

Abdominal pain

+++

Trasmural damage

++

Granulomas

++

Cobblestoning mucosa

++

Asymmetria

+++

Involvement of ilea

+++

Rectal damage

20%

100%

Rectal bleeding

50%

++

Strictures, fistulas

+++

Crypt abscesses

+++

Treatment of IBD

Increase of agression

Experimental treatment
(IL 10, azathioprin iv)
Inhibitor of tumor necrosis
factor (TNF )
Cytostatics
Corticosteroids
Antibiotics
Sulfonamides, salysilates