Problem 1

Gastrointestinal System
Block

Learning Objective
Explain:
1. Anatomy, Histology, and Biochemistry Upper Gastrointestinal
Tract
2. Physiology Upper Gastrointestinal Tract
3. The causes of dysphagia :
(Definition, epidemiology, Etiology, risk factor, sign and
symptom, Patophysiology, pysical examinatin, Lab examination,
DD, Treatment (with prescription and how examine),
complication, Prognosis)
Swelling : caries dentis,infeksiabses (selulitis), angina
ludwig,parotitis, glossitis, micrognatia and macrognatia,cancer
White patches: leukoplakia, candidiasis,stomatitis
Hereditary : Esophageal atresia, reflux esophaghitis,
achalasia,cleft lip and palate
Ulcer : Aphthous, herpes, corrosive lession of eshophagus

LO 1
Anatomy, Histology, and Biochemistry Upper Gastrointestinal Tract

Anatomy lateral view and PA viewAnatomy of the oral cavity and

pharynx in (A) the lateral view and (B) posterior view (After Banks et
al., 2005, used with permission Two figures from Atlas of Clinical Gross
Anatomy By Kenneth Moses et al. Elsevier; 2005. ISBN 0323037445
P104, Fig 10.1 Divisions of the pharynx P105, Fig 10.3 Posterior view of
the pharynx)

http://www.dysphagiaonline.com/nl/PublishingImages/Swallowing_Mechanism.jpg

LO 2
Physiology Upper Gastrointestinal Tract

1) Stage I transport
When food is ingested into the mouth, the
tongue carries the food to the post-canine
region and rotates laterally, placing the food
onto the occlusal surface of lower teeth for
food processing.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597750/

2) Food Processing
Food processing immediately follows stage I
transport. During food processing, food particles
are reduced in size by mastication and softened
by salivation until the food consistency is
optimal for swallowing. Chewing continues until
all of the food is prepared for swallowing. Cyclic
movement of the jaw in processing is tightly
coordinated with the movements of the tongue,
cheek, soft palate and hyoid bone (Fig. 3).

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597750/

3. Stage II transport: Drawings based on a

videofluorographic recording. The tongue squeezes the
bolus backward along the palate, through the fauces, and
into the pharynx when the upper and lower teeth are
closest together and during early jaw opening phase (first
three frames). The bolus head reaches the valleculae
while food processing continues (last two frames).
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597750/

Pharyngeal stage
Pharyngeal swallow is a rapid sequential activity, occurring within a

second. It has two crucial biological features: (1) food passage,

propelling the food bolus through the pharynx and UES to the
esophagus; and (2) airway protection, insulating the larynx and
trachea from the pharynx during food passage to prevent the food
from entering the airway.
During the pharyngeal stage, the soft palate elevates and contacts the
lateral and posterior walls of the pharynx, closing the nasopharynx at
about the same time that the bolus head comes into the pharynx (
Fig. 5). Soft palate elevation prevents bolus regurgitation into the nasal
cavity. The base of the tongue retracts, pushing the bolus against the
pharyngeal walls (Fig. 5). The pharyngeal constrictor muscles contract
sequentially from the top to the bottom, squeezing the bolus
downward. The pharynx also shortens vertically to reduce the volume
of the pharyngeal cavity.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597750/

the diagram of swallowing a

liquid bolus

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597750/

Esophageal stage
The esophagus is a tubular structure from the lower part of the UES to

the lower esophageal sphincter (LES). The lower esophageal sphincter

is also tensioned at rest to prevent regurgitation from the stomach. It
relaxes during a swallow and allows the bolus passage to the
stomach. The cervical esophagus (upper one third) is mainly
composed of striated muscle but thoracic esophagus (lower two
thirds) is smooth muscle. Bolus transport in the thoracic esophagus is
quite different from that of the pharynx, because it is true peristalsis
regulated by the autonomic nervous system. Once the food bolus
enters the esophagus passing the UES, a peristalsis wave carries the
bolus down to stomach through the LES. The peristaltic wave consists
of two main parts, an initial wave of relaxation that accommodates
the bolus, followed by a wave of contraction that propels it. Gravity
assists peristalsis in upright position.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597750/

LO 3

Swelling :
caries dentis,infeksiabses
(selulitis), angina ludwig,parotitis,
glossitis, m icrog natia and
m acrog natia,cancer

Angina ludwig
Angina ludwig is an infection of the floor of

the mouth under the tongue. Its due to

bacteria
It often develops after an infection of the roof
of teeth (such as tooth abcess) or a mouth
injury
The infection area swells quickly. This may
block the airway or prevent you from
swallowing saliva

www.nlm.nih.gov

Angina Ludwig
Symptoms:
Breathing difficulty
Confusion or other mental changes
Fever
Neck pain
Neck swelling
Redness of the neck
Weakness, fatigue, excess tiredness

www.nlm.nih.gov

Treatment
If the swelling blocks the airway get emergency
medical help right away. A breathing tube through
your mouth or nose and into the lungs to restore
breathing. Tracheostomy that creates an opening
through the neck into the windpipe
Antibiotics to fight the infection. Antibiotics taken by
mouth may be continued until tests show that the
bacteria have gone away
Dental treatment for tooth infections taht couse
Ludwigs Angina
Surgery to drain fluids that are causing the swelling

www.nlm.nih.gov

Prognosis : ludwigs angina can be life

threatening. However, it can be cured with

getting treatment to keep the airways open
and taking antibiotic medicine
Komplikasi : airway blockage, generalized
infection (sepsis), septic shock

www.nlm.nih.gov

Glosittis
A problem in which the tongue is swollen and changes color,

often making the surface of the tongue appear smooth

Causes:
Allergic reactions to oralcare products, foods, or medicine
Dry mouth due to Sjogren syndrome
Infection from bacteria, yeast or viruses (including oral herpes)
Injury (such as from burns, rough teeth, or bad-fitting dentures0
Skin conditions that affect the mouth
Irritants such as tobacco, alcohol, hot foods, spices, or other

irritants
Hormonal factors
Genetics

Symptoms
Symptoms of glossitis may come on quickly or

develop over time. They include:

Problems chewing, swallowing, or speaking
Smooth surface of the tongue
Sore, tender, or swollen tongue
Pale or bright red color to the tongue
Tongue swelling
Rare symptoms or problems include
blocked airway
Problems speaking, chewing, or swallowing

Exams and Tests

Your dentist or health care provider will do an

exam to look for:

Finger-like bumps on the surface of the tongue

(called papillae) that may be missing

Swollen tongue (or patches of swelling)

The health care provider may ask questions

about your health history and lifestyle to help

discover the cause of tongue inflammation.
You may need blood tests may be done to rule
out other medical problems.

Treatment
The goal of treatment is to reduce swelling and

soreness. Most people do not need to go to the

hospital unless the tongue is very swollen.
Treatment may include:
Good oral care. Brush your teeth thoroughly at
least twice a day and floss at least once a day.
Antibiotics or other medicines to treat infection.
Diet changes and supplements to treat nutrition
problems.
Avoiding irritants (such as hot or spicy foods,
alcohol, and tobacco) to ease discomfort.

ESOPHAGEAL CANCER
Sign and Symptoms
Dysphagia (most common); initially for solids, eventually

progressing to include liquids

Weight loss (second most common)
Bleeding
Epigastric or retrosternal pain
Bone pain with metastatic disease
Hoarseness
Persistent cough
Physical findings include the following:
Typically, normal examination results unless the cancer has

metastasized
Hepatomegaly (from hepatic metastases)
Lymphadenopathy in the laterocervical or supraclavicular areas
(reflecting metastasis)

DIAGNOSIS
Laboratory studies focus principally on patient factors that may

affect treatment (eg, nutritional status).

Imaging studies used for diagnosis and staging include the
following:
Esophagogastroduodenoscopy (allows direct visualization and

biopsies of the tumor)

Endoscopic ultrasonography (EUS; most sensitive test for T and N
staging)
Computed tomography of the abdomen and chest (for assessing lung
and liver metastasis and invasion of adjacent structures)
Positron emission tomography (PET) scanning (for staging)
Bronchoscopy (to help exclude invasion of the trachea or bronchi)
Laparoscopy and thoracoscopy (for staging regional nodes)
Barium swallow (very sensitive for detecting strictures and
intraluminal masses, but now rarely used)

ETIOLOGY
Smoking & alcohol use
Caustic injuries
Certain foodstuffs (eg, betel nut)
Drinking scalding-hot liquids
Environmental contributors (eg, nitrosamines in

soil)
Certain fungi, molds, or yeasts
Acquired conditions (eg, achalasia)
Infections HPV, Helicobacter pylori
GERD

Oral Cancer

Oral Cancer
Symptoms
Swellings/thickenings, lumps or bumps, rough spots/crusts/or eroded areas

on the lips, gums, or other areas inside the mouth

The development of velvety white, red, or speckled (white and red)
patches in the mouth
Unexplained bleeding in the mouth
Unexplained numbness, loss of feeling, or pain/tenderness in any area of
the face, mouth, or neck
Persistent sores on the face, neck, or mouth that bleed easily and do not
heal within 2 weeks
A soreness or feeling that something is caught in the back of the throat
Difficulty chewing or swallowing, speaking, or moving the jaw or tongue
Hoarseness, chronic sore throat, or change in voice
Ear pain
A change in the way your teeth or dentures fit together
Dramatic weight loss

Risk Factor
Smoking. Cigarette, cigar, or pipe smokers are six times

more likely than nonsmokers to develop oral cancers.

Smokeless tobacco users. Users of dip, snuff, or chewing
tobacco products are 50 times more likely to develop
cancers of the cheek, gums, and lining of the lips.
Excessive consumption of alcohol. Oral cancers are
about six times more common in drinkers than in
nondrinkers.
Family history of cancer.
Excessive sun exposure, especially at a young age.
Human papillomavirus (HPV). Certain HPV strains are
etiologic risk factors for Oropharyngeal Squamous Cell
Carcinoma (OSCC)

White patches

CANDIDIASIS
Candidiasis of the mouth and throat , also

known as thrush" or oropharyngeal

candidiasis, is a fungal infection that occurs
when there is overgrowth of a yeast called
Candida, the most common of which is
Candida albicans.
Candida yeasts normally live on the skin or
mucous membranes in small amounts.
However, if the environment inside the mouth
or throat becomes imbalanced, the yeasts can
multiply and cause symptoms.

ETIOLOGY
Candida species are normal inhabitants of the

mouth, throat, and the rest of the

gastrointestinal tract.
Usually, Candida yeasts live in and on the
body in small amounts and do not cause any
harm.
However, the use of certain medications or a
weakening of the immune system can cause
Candida to multiply, which may cause
symptoms of infection.

symptoms
The most common symptom of oral thrush is
white patches or plaques on the tongue and
other oral mucous membranes.
Other symptoms include:
Redness or soreness in the affected areas
Difficulty swallowing
Cracking at the corners of the mouth (angular
cheilitis)

Treatment & Outcomes

Oral candidiasis usually responds to topical

treatments such as clotrimazole troches

and nystatin suspension
Systemic antifungal medication such as
fluconazole or itraconazole .
Candida esophagitis is typically treated with
oral or intravenous fluconazole or oral
itraconazole.

Oral Leukoplakia
Oral leukoplakia (OL) is a white patch or plaque

that cannot be rubbed off, cannot be

characterized clinically or histology as any other
condition, and is not associated with any physical
or chemical causative agent except tobacco.
The etiology of most cases of OL is unknown
(idiopathic). Factor most frequently blamed for
the development of idiopathic leukoplakia
include tobacco use, alcohol cosumption, chronic
irritation, candidiasis, vitamin, deficiency,
endocrine disturbance, and posibly a virus.

www.medscape.com

OL is more common in men than in women,

with a male-to-women of 2:1

Most cases of OL occur in persons in their fifth
to seventh decade of life

www.medscape.com

Hereditary

Reflux esophaghitis
Gastroesophageal reflux disease (GERD) is a

condition in which the stomach contents leak

backwards from the stomach into the
esophagus (the tube from the mouth to the
stomach). This can irritate the esophagus and
cause heartburn and other symptoms.

Causes

When you eat, food passes from the throat to the

stomach through the esophagus. A ring of muscle

fibers in the lower esophagus prevents swallowed
food from moving back up. These muscle fibers
are called the lower esophageal sphincter, or LES.
When this ring of muscle does not close all the
way, stomach contents can leak back into the
esophagus. This is called reflux or
gastroesophageal reflux. Reflux may cause
symptoms. Harsh stomach acids can also
damage the lining of the esophagus.

The risk factors

Use of alcohol
Hiatal hernia (a condition in which part of the

stomach moves above the diaphragm, which

is the muscle that separates the chest and
abdominal cavities)
Obesity
Pregnancy
Scleroderma
Smoking

Heartburn and gastroesophageal reflux can be

brought on or made worse by pregnancy. Symptoms
can also be caused by certain medicines, such as:
Anticholinergics (e.g., for seasickness)
Beta-blockers for high blood pressure or heart

disease
Bronchodilators for asthma
Calcium channel blockers for high blood pressure
Dopamine-active drugs for Parkinson's disease
Progestin for abnormal menstrual bleeding or birth
control
Sedatives for insomnia or anxiety
Tricyclic antidepressants

Symptoms
Common symptoms of GERD include:
Feeling that food is stuck behind the breastbone
Heartburn or a burning pain in the chest
Nausea after eating
Less common symptoms are:
Bringing food back up (regurgitation)
Cough or wheezing
Difficulty swallowing
Hiccups
Hoarseness or change in voice
Sore throat

Exams and Tests

upper endoscopy (EGD)

: This is a
test to examine the lining of the esophagus (the
tube that connects your throat to your stomach),
stomach, and first part of the small intestine.
It is done with a small camera (flexible endoscope)
that is inserted down the throat.

A test that measures how often

stomach acid enters the tube that

leads from the mouth to the
stomach (called the esophagus) : A test to
measure the pressure inside the lower part of the
esophagus (esophageal manometry).

Treatment

lifestyle changes to help treat your symptoms.

Diet
Avoid drugs such as aspirin, ibuprofen (Advil, Motrin), or

naproxen (Aleve, Naprosyn). Take acetaminophen (Tylenol)

to relieve pain.
Take all of your medicines with plenty of water. When your
doctor gives you a new medicine, ask whether it will make
your heartburn worse.
Proton pump inhibitors (PPIs) decrease the amount of acid
produced in your stomach
H2 blockers also lower the amount of acid released in the
stomach
Anti-reflux surgery may be an option for patients whose
symptoms do not go away with lifestyle changes and drugs.
Heartburn and other symptoms should improve after
surgery. But you may still need to take drugs for your
heartburn.

Complications
Worsening of asthma
A change in the lining of the esophagus that can

increase the risk of cancer (Barrett's esophagus)

Bronchospasm (irritation and spasm of the
airways due to acid)
Chronic cough or hoarseness
Dental problems
Ulcer in the esophagus
Stricture (a narrowing of the esophagus due to
scarring)

Achalasia
Achalasia is a disorder of the esophagus, the

tube that carries food from the mouth to the

stomach. This condition affects the ability of
the esophagus to move food into the stomach.

https://www.nlm.nih.gov/medlineplus/ency/article/000267
.htm

Etiology
There is a muscular ring at the point where the esophagus and

stomach meet, called the lower esophageal sphincter.

Normally, this muscle relaxes when you swallow. In people with
achalasia, it does not relaxas well. In addition, the normal
muscle activity of the esophagus (peristalsis) is reduced.
This problem is caused by damage to the nerves of the
esophagus.
Other problems can cause similar symptoms, such as cancer of
the esophagus or upper stomach, and a parasite infection that
causesChagas disease.
Achalasia is rare. It may occur at any age, but is most common
in middle-aged or older adults. The problem may be inherited
in some people.
https://www.nlm.nih.gov/medlineplus/ency/article/000267
.htm

Symptoms
Backflow (regurgitation) of food
Chest pain, which may increase after eating

or may be felt in the back, neck, and arms

Cough
Difficulty swallowing liquids and solids
Heartburn
Unintentional weight loss

https://www.nlm.nih.gov/medlineplus/ency/article/000267
.htm

Exams and Tests

Physical exam may show signs ofanemiaor

malnutrition.
Tests include:
Esophageal manometry
Esophagogastroduodenoscopy
Upper GI x-ray

https://www.nlm.nih.gov/medlineplus/ency/article/000267
.htm

Treatment
The goal of treatment is to reduce the pressure at the lower

esophageal sphincter. Therapy may involve:

Injection with botulinum toxin (Botox). This may help relax
the sphincter muscles. However, the benefit wears off within
a few weeks or months.
Medications, such as long-acting nitrates or calcium channel
blockers. These drugs can be used to relax the lower
esophagus sphincter.
Surgery (called an esophagomyotomy). This procedure may
be needed to decrease the pressure in the lower sphincter.
Widening (dilation) of the esophagus at the location of the
narrowing. This is done during esophagogastroduodenoscopy.
https://www.nlm.nih.gov/medlineplus/ency/article/000267
.htm

Outlook (Prognosis)
The outcomes of surgery and nonsurgical

treatments are similar. Sometimes more than

one treatment is necessary.

https://www.nlm.nih.gov/medlineplus/ency/article/000267
.htm

Complication
Complications may include:
Backflow (regurgitation) of acid or food from

the stomach into the esophagus (reflux)

Breathing food contents into the lungs
(aspiration), which can cause pneumonia
Tearing (perforation) of the esophagus

https://www.nlm.nih.gov/medlineplus/ency/article/000267
.htm

Cleft lip and palate

Cleft Lip

The lip forms between the fourth and seventh weeks of

pregnancy. A cleft lip happens if the tissue that makes up the
lip does not join completely before birth. This results in an
opening in the upper lip. The opening in the lip can be a small
slit or it can be a large opening that goes through the lip into
the nose. A cleft lip can be on one or both sides of the lip or in
the middle of the lip, which occurs very rarely. Children with a
cleft lip also can have a cleft palate.

http://www.cdc.gov/ncbddd/birthdefects/cleftlip.html

Cleft Palate

The roof of the mouth (palate) is formed between the sixth

and ninth weeks of pregnancy. A cleft palate happens if the
tissue that makes up the roof of the mouth does not join
together completely during pregnancy. For some babies,
both the front and back parts of the palate are open. For
other babies, only part of the palate is open.

http://www.cdc.gov/ncbddd/birthdefects/cleftlip.html

Occurrence
CDC recently estimated that, each year in the

United States, about 2,650 babies are born

with a cleft palate and 4,440 babies are born
with a cleft lip with or without a cleft palate. 1
Isolated orofacial clefts, or clefts that occur
with no other major birth defects, are one of
the most common types of birth defects in the
United States.1Depending on the cleft type,
the rate of isolated orofacial clefts can vary
from 50% to 80%
http://www.cdc.gov/ncbddd/birthdefects/cleftlip.html

Causes
The causes of orofacial clefts among most

infants are unknown. Some children have a

cleft lip or cleft palate because of changes in
theirgenes. Cleft lip and cleft palate are
thought to be caused by a combination of
genes and other factors, such as things the
mother comes in contact with in her
environment, or what the mother eats or
drinks, or certain medications she uses during
pregnancy.
http://www.cdc.gov/ncbddd/birthdefects/cleftlip.html

Recently, CDC reported on important findings from

research studies about some factors that increase the

chance of having a baby with an orofacial cleft:
SmokingWomen who smoke during pregnancy are

more likely to have a baby with an orofacial cleft than

women who do not smoke.2-3
DiabetesWomen with diabetes diagnosed before
pregnancy have an increased risk of having a child with
a cleft lip with or without cleft palate, compared to
women who did not have diabetes. 5
Use of certain medicinesWomen who used certain
medicines to treat epilepsy, such as topiramate or
valproic acid, during the first trimester (the first 3
months) of pregnancy have an increased risk of having
a baby with cleft lip with or without cleft palate,
compared to women who didnt take these medicines. 6-7
http://www.cdc.gov/ncbddd/birthdefects/cleftlip.html

Diagnosis
Orofacial clefts, especially cleft lip with or

without cleft palate, can be diagnosed during

pregnancy by a routine ultrasound. They can
also be diagnosed after the baby is born,
especially cleft palate. However, sometimes
certain types of cleft palate (for example,
submucous cleft palate and bifid uvula) might
not be diagnosed until later in life.

http://www.cdc.gov/ncbddd/birthdefects/cleftlip.html

Management and Treatment

Children with a cleft lip with or without a cleft palate or a cleft palate alone often have

problems with feeding and speaking clearly, and can have ear infections. They also might
have hearing problems and problems with their teeth. Services and treatment for children
with orofacial clefts can vary depending on the severity of the cleft; the childs age and
needs; and the presence of associated syndromes or other birth defects, or both.
Surgery to repair a cleft lip usually occurs in the first few months of life and is
recommended within the first 12 months of life. Surgery to repair a cleft palate is
recommended within the first 18 months of life or earlier if possible. 8Many children will
need additional surgical procedures as they get older. Surgical repair can improve the look
and appearance of a childs face and might also improve breathing, hearing, and speech
and language development. Children born with orofacial clefts might need other types of
treatments and services, such as special dental or orthodontic care or speech therapy. 4,8
Because children with orofacial clefts often require a variety of services that need to be
provided in a coordinated manner throughout childhood and into adolescence and
sometimes adulthood, the American Cleft Palate - Craniofacial Association recommends
services and treatment by cleft and craniofacial teams. 8Cleft and craniofacial teams
provide a coordinated approach to care for children with orofacial clefts. These teams
usually consist of experienced and qualified physicians and health care providers from
different specialties.

http://www.cdc.gov/ncbddd/birthdefects/cleftlip.html

Ulcer

Corrosive Lession of
Esophagus
Acute poisonings with corrosive substances

may cause serious chemical injuries to upper

gastrointestinal tract, the most common
location being the esophagus and the
stomach.

http://manu.edu.mk/prilozi/6ca.pdf

 Corrosive esophagitis is caused by

swallowing of caustic chemicals (acid
or lye) accidentally or in a suicide
attempt. The severity of the
inflammation depends on the type,
amount, and concentration of caustic
chemical swallowed.

Causes and Risk Factors of

Esophagitis
Chemicals especially likely to cause very severe
corrosive Esophagitis include cleaning or disinfectant
solutions.
Factors that contribute to the development of reflux
esophagitis include the caustic nature of the refluxate,
the inability to clear the refluxate from the esophagus,
the volume of gastric contents, and local mucosal
protective functions.
Poor lower esophageal segment functioning may be
associated with a hiatal hernia, in which the top part
of the stomach slides back and forth between the
chest and the abdomen. Symptoms may be worsened
by alcohol, smoking, sedentary lifestyle and obesity.

Symptoms of Esophagitis
The main symptom of reflux
esophagitis is heartburn, with or
without regurgitation of gastric
contents into the mouth, which
worsens on bending over.
Complications of GERD include
esophagitis and possibly massive but
limited hemorrhage.

Treatment of Esophagitis
Management consists of:
Elevating the head of the bed
Avoiding strong stimulants of acid secretions (e.g.,
coffee, alcohol)
Avoiding certain drugs (e.g., anticholinergics), specific
foods (fats, chocolate), and smoking, all of which lower
esophageal sphincter competence
Giving an antacid to neutralize gastric acidity and
possibly increase lower esophageal sphincter
competence
Use of cholinergic agonists to increase sphincter
pressure
Use of H2 agonists to reduce stomach acidity
Surgical treatment may be necessary to correct a
hiatal hernia.

Examinatination
Esophagogastroduodenoscopy gives useful data on the

existence of post-corrosive injuries and if they are

documented, then an adequate treatment has to be initiated
as soon as possible .
Endoscopic classification of post-corrosive injuries in the upper
gastrointestinal tract is of enormous importance in diagnosis
and treatment of acute corrosive intoxications.
Kikendall suggested a classification in four grades:
I GRADE: edema and erythema of the mucosa,
II A GRADE: hemorrhage, erosions, blisters, superficial ulcers,
III B GRADE: circumferential lesions,
III GRADE: deep grey or brownish-black ulcers,
IV GRADE: perforation
http://manu.edu.mk/prilozi/6ca.pdf

Some authors use the classification by Zargar:

Grade 0: normal mucosa,

Grade I: edema and erythema of the mucosa,
Grade II A: hemorrhage, erosions, blisters,
superficial ulcers,
Grade II B: circumferential lesions,
Grade III A: focal deep gray or brownish-black
ulcers,
Grade III B: extensive deep gray or brownishblack ulcers,
Grade IV: perforation

http://manu.edu.mk/prilozi/6ca.pdf

http://manu.edu.mk/prilozi/6ca.pdf

Treatment (with prescription and

how examine)
Neutralization of corrosive substances: A large number of

authors who are involved with the problem of caustic

intoxications think that neutralization is contraindicated.
In order to be effective, it must be done within the first
hour after ingestion of a caustic agent . A
lkalis can be neutralized with mild vinegar, lemon or
orange juice. Acids can be neutralized with milk, eggs or
antacids
Sodium bicarbonate is not recommended because it
produces carbon dioxide, which increases the risk of
perforation. Some authors think that the heat produced in
the neutralization reaction increases the possibility of
additional injuries of upper gastrointestinal tract.
http://manu.edu.mk/prilozi/6ca.pdf

Emetics are contraindicated because of re-exposition to corrosive

substance leading to injury exacerbation. Active coal is also

contraindicated.
Corticosteroids Several studies including 361 patients showed
19% of esophageal and stomach stenosis in patients treated with
corticosteroids and 41% of stenosis in those not receiving
corticotherapy. Dexamethasone of 1 mg/kg/day or prednisolone of
2 mg/kg/day was given to these patients [53, 54]. Some studies
did not prove the preventive effect of corticosteroids in stricture
formation but corticosteroids may increase the risk of onset of
peritonitis or mediastinitis. Such multicentric study comprising
572 patients conducted at the same time in several European
countries indicated that corticosteroids had no significant
influence on prevention of post-corrosive stenosis in acute
corrosive poisonings
http://manu.edu.mk/prilozi/6ca.pdf

Nutrition
In patients with I and II A degree of damage, total parenteral

nutrition in the first 2448 hours is followed by a liquid diet until

the 10th day. Afterwards, food intake can be in a more liberal
regimen. In patients with II B and III degree of damage the socalled esophageal rest is recommended, that is the patient must
not take food per os. During the "rest", the patient is fed by
nasogastric or nasoenteral tube, gastrostoma or jejunostoma and
parenterally by peripheral or central vein. This is explained by the
fact that food particles enter the granulocytes of the esophageal
wall and exacerbate the inflammation
Esophageal rest may last until the 10th day after corrosive
ingestion or some authors say until the 15th day, that is, until the
first endoscopic control [58]. Some authors recommend taking
liquids (liquid nutritional solutions, milk) 48 hours after ingestion if
the patient can swallow his/her saliva
http://manu.edu.mk/prilozi/6ca.pdf

Recommendations
In spite of the good screening results and modern

treatment of patients with acute corrosive

poisonings, the American Society of
Gastrointestinal Endoscopy (ASGE) gives several
recommendations for monitoring of patients with
caustic injuries to upper gastrointestinal tract:
surveillance of patients 15 to 20 years after
corrosive ingestion;
endoscopic examination every three years;
reduction of the threshold for evaluation of
dysphagia
http://manu.edu.mk/prilozi/6ca.pdf

Complication
Late complications are a major problem in acute corrosive

poisoning and often cause permanent handicap in patients.

Sophisticated diagnostics and treatment over the last several
years have substantially reduced the percentage of late
complications related to acute corrosive intoxications and
injuries in the upper gastrointestinal trac
The most common late complications are esophageal strictures
and stenosis, gastric stenosis of the antrum and pylorus,
esophageal and stomach cancer.
Strictures and stenosis of the esophagus may appear three
weeks after ingestion of the corrosive substance, in the first
three months or even after one year according to some
authors. Liquid corrosive substance ingestion more often
initiates stenosis than corrosive substances in crystal state
http://manu.edu.mk/prilozi/6ca.pdf

Prognosis
Prognosis in acute corrosive poisonings is

variable and depends on the degree of

esophageal and gastric injury as well as on
the general health condition of the patient.
The highest mortality rate has been recorded
as a result of perforation and mediastinitis.

HERPES

Herpes
Etiology: Herpes Simplex Virus
Mouth sores most commonly occur in children

aged 1-2 years, but they can affect people at

any age and any time of the year.
People contract herpes by touching infected
saliva, mucous membranes, or skin. Because
the virus is highly contagious, most people
have been infected by at least 1 herpes
subtype before adulthood.

STAGES
After the herpes virus infects you, it has a rather unique ability

to proceed to 3 stages
Primary infection: The virus enters your skin or mucous

membrane and reproduces. During this stage, oral sores and

other symptoms, such as fever, may develop
The virus may not cause any sores and symptoms. You may not know
that you have it. This is called asymptomatic infection.
Asymptomatic infection occurs twice as often as the disease with
symptoms.

Latency: From the infected site, the virus moves to a mass of

nervous tissue in your spine called the dorsal root ganglion.

There the virus reproduces again and becomes inactive
Recurrence: When you encounter certain stresses, emotional or
physical, the virus may reactivate and cause new sores and
symptoms.

Symptoms
Incubation period:
For oral herpes, the amount of time between contact with the virus and the appearance of
symptoms, the incubation period, is 2-12 days. Most people average about 4 days.
Duration of illness: Signs and symptoms will last 2-3 weeks. Fever, tiredness, muscle

aches, and irritability may occur

Pain, burning, tingling, or itching occurs at the infection site before the sores appear. Then

clusters of blisters erupt. These blisters break down rapidly and, when seen, appear as tiny,
shallow, gray ulcers on a red base. A few days later, they become crusted or scabbed and
appear drier and more yellow
Oral sores: The most intense pain caused by these sores occurs at the onset and make eating
and drinking difficult.

The sores may occur on the lips, the gums, the front of the tongue, the inside of the cheeks, the throat, and
the roof of the mouth.

They may also extend down the chin and neck.

The gums may become mildly swollen and red and may bleed.

Neck lymph nodes often swell and become painful.

In people in their teens and 20s, herpes may cause a painful throat with shallow ulcers and a grayish
coating on the tonsils.

Medication
Treatment includes medication for fever and taking plenty of fluids.
A topical anesthetic such as viscous lidocaine (Dilocaine, Nervocaine, Xylocaine,

Zilactin-L) may be prescribed to relieve pain.

Oral or IV medication does exist for herpes but is not recommended for people with a

normal immune system. It is used only for people with weakened immune systems,
infants younger than 6 weeks, or people with severe disease.
Some people may require hospital admission:
Those with severe local infection
People whose infection has spread to other organ systems
People with weakened immune systems
Dehydrated individuals who need IV hydration
Infants younger than 6 weeks