Ulceroinflammatory Disorders of
the GIT
Dr. Mehzabin Ahmed
TOPICS
Common symptoms & terminology
Disorders of :
Mouth: Ulcers, Premalignant lesions
Pharynx: Infections, Tumors
Salivary gland: Inflammations, Tumors
Esophagus: Hiatus hernias, Barrett esophagus
Stomach: Peptic ulcers
Intestines: Inflammatory bowel disease (Crohn
disease & ulcerative colitis) and Malabsorption
syndromes
The gastrointestinal tract extends from the mouth to the
anus and includes the oral cavity and salivary glands,
pharynx, oesophagus, stomach, small and the large
intestines.
The main function of the GIT is digestion, absorption
and assimilation of the food consumed.
1. Dysphagia: Difficulty in swallowing.
Causes :
Acute infections of the pharynx or tonsils, or
Obstruction by foreign bodies or tumors (in the oesophagus
or outside it producing compression) or
Impaired neuromuscular function (as in achalasia cardia or
multiple sclerosis)
2. Leukoplakia: is a term used to describe the white patches of
keratosis (increased keratinization) resulting due a chronic
irritation. It is characterized by
Hyperkeratinization and hyperplasia of the squamous
epithelium
Dysplasia in some cases and in these situations it is
premalignant.
4. Abdominal pain: it can originate in the
a) Viscera: due to spasm or colic of the muscular layer of the gut
b) Peritoneum: due to irritation or inflammation
5. Blood loss: it may be as
a) Hematemesis: Vomiting of blood- usually due to an upper GI
bleeding, due to:
Oesophagus: ruptured blood vessels (oesophageal varices) r
Stomach: due to
an erosion by an ulcer
Mallory Weis syndrome (oesophageal mucosal tears in
chronic alcoholic occurring due to retching and vomiting
b) Melena: passage of altered blood in the stools.
the blood lost may originate from
- Upper GI:. It occurs in ulcers and tumors of the stomach and
duodenum
- Lower GI: the blood in the stools appears fresh and red. It occurs
in ruptures anal fissures, hemorrhoids (piles), or ulcers and
tumors of the colorectum.
6. Weight loss: it may be due
· Impaired food intake: as in eating disorders
· Malabsorption syndromes
· Increased catabolism a/w a malignant tumor.
7. Anaemia: it may be due to blood loss or due to impaired absorption of
iron, folic acid or B12 (either due to a mucosal abnormality eg.
pernicious anaemia or to a defect in the transport proteins)
8. Diarrhoea: Causes: an impaired absorption (usually due to an infective
cause as in cholera, shigellosis and are called infective diarrhoeas) or
excessive secretion of fluid (osmotic diarrhoea- as in lactose
intolerance)
9. Steatorrhoea: due to impaired absorption of fat either because of
reduced lipase secretion or reduced absorption area or due to lymphatic
obstruction.
Mouth
Ulcers: The oral mucosa is commonly affected by ulcers.
These may be
infectious (herpes virus, candida albicans) or
non infectious (aphthous ulcers- due to an
immunological imbalance, or associated with Crohn’s
disease- usually self limited).
Leukoplakia: premalignant lesion resulting from a chronic
irritation- if untreated leads to squamous cell carcinoma.
Aphthous
ulcers
Leukoplakia- hyperkeratosis
PHARYNX
Most infections of the pharynx are due to a
viral infection like influenza, measles, rhinovirus, infectious
mononucleosis.
Bacterial infections due to streptococcus
important because of their complications, like rheumatic
fever and its complications, glomerulonephritis, and
vascultis.
Tumors: Ebstein Barr virus is implicated in the development of
Nasopharyngeal carcinoma.
Salivary glands
Inflammations of the salivary glands is called sialedinitis.
It may be due to bacterial/ viral infections or autoimmune
reaction.
Bacterial infections can act as a nidus for stone formation,
resulting in duct obstruction.
Tumors:
the most common tumor of the salivary gland is the mixed
tumor or the pleomorphic adenoma.
The adenoid cystic carcinoma is a malignant tumor of the
salivary glands that involves the parotid gland, and commonly
extends and infiltrates into the facial nerve leading to
paralysis.
Esophagus
Congenital conditions like
Atresia (failure to canalize/ absence of the lumen)
Diverticula (formation of outpouchings in the wall)
Tracheoesophageal fistula (fistula-abnormal connections between
two hollow organs) may be seen.
Hiatus hernia is the presence of a part of the stomach above the
diaphragmatic orifice. It may be due to
a congenital shortening of the esophagus, or
in aged patients due to increased abdominal pressure coupled with a
decreased diaphragmatic muscle tone.
Achalasia is a condition when the contractility of the lower esophagus is
lost and failure of relaxation of the sphincter. It may be due to
destruction or degeneration of the myentric plexus as in neurotropic
infection like Chaga’s disease or
due a congenital absence of the ganglion cells of the myentric plexus.
Esophageal atresia
A B C
A,B-Tracheoesophageal fistulas
C- Esophagela atresia with fistula
Oesophageal varices are dilated veins of the lower esophagus,
which serve as shunts when portal venous flow through the liver
is impaired. It is a cause for massive hematemesis. Other sites of
varices are around the anus and the umbilicus.
Reflux esophagitis is a chronic inflammation in the esophagus
occurring as a result of the regurgitation of the acidic gastric
contents. It produces heartburn
Barrett’s esophagus is a metaplastic change in the mucosal
lining of the lower esophagus, from stratified nonkeratinized
epithelium to columnar epithelium, occurring as a result of
longstanding reflux. Its significance lies in the fact that it is
premalignant.
Tumors involving the oesophagus could be benign like the
leiomyoma (smooth muscle tumor) or carcinoma (squamous cell
carcinoma or the adenocarcinoma).
Stomach
Congenital pyloric stenosis is the hypertrophy of the circular
muscle coat of the pyloric sphincter leading to an outflow
obstruction.
Acute gastritis:
It is the acute inflammation of the stomach in response to an
irritant chemical like drugs or alcohol.
The principal drugs implicated are the nonsteroidal anti-
inflammatory drugs (NSAIDs), notably aspirin.
These agents result in exfoliation of the surface epithelial cells
and decrease the secretion of the mucus.
Inhibit the prostaglandin synthesis.
Other causes include
excessive alcohol ingestion,
heavy smoking,
cancer chemotherapy,
severe stress as in burns/trauma/surgery (Curling’s ulcers),
irradiation,
ingestion of acids/ alkali,
systemic infection and
ischemia and shock.
Depending on the severity there may be lesions ranging from
vasodilatation and edema to
erosions and hemorrhage. Erosion is a partial loss of mucosa whereas an
ulcer is a full thickness loss. Erosions in acute gastritis are usually multiple
and frequently bleed causing hemorrhage.
Chronic gastritis is frequently due to Helicobacter pylori infection, or may
be autoimmune (associated with vitamin B12 deficiency resulting in
megaloblastic anemia- pernicious anemia) or chemical injury due to NSAIDs,
chronic bile reflux or alcohol, radiation, post surgery, obstruction, and
chronic granulomatous conditions like Crohn’s disease.
Peptic ulceration
Ulcers are a breach in the continuity of the mucosal epithelial
lining of the alimentary tract extending through the muscularis
mucosa into the submucosa or deeper, arising as a result of the
acid and pepsin attacks on the mucosa.
Normally these attacks are counteracted by the defense
mechanism like
the mucus- bicarbonate barrier,
increased mucosal blood flow,
increased regenerative capacity of the epithelium and
prostaglandin secretion by the epithelium.
Ulcers result when the mucosal defenses are weakened or when
the damaging forces are increased.
This occurs in:
Helicobacter pylori infection-
releases enzymes (digests the mucosal lining) and
lipopolysaccharides (attract the inflammatory cells which
release digestive enzymes) and
a platelet activating factor that promotes the thrombotic
occlusion of the surface capillaries (promotes ischemic
damage)
Chronic use of NSAIDs- these suppress the prostaglandin
secretion
Increased gastric acidity as in gastrinomas (increased gastrin
secretion)- Zollinger Ellison syndrome.
Chronic smoking, alcohol ingestion, corticosteroid
administration are other causes.
Major sites include first part of the duodenum, junction of the
antrum and the body of the stomach, distal oesophagus, at the
gastro enterostomy stoma (post partial gastrectomy patients) and
in Meckles diverticula (sac like out pouching from the intestinal
wall)
Clinically the patient presents with a burning pain, which is
worse at night and 1-3 hours after meals, nausea, vomiting,
bloating, belching, and weight loss.
Complications of the ulcers include hemorrhage, anemia,
extension and perforation of the ulcers, and obstruction due to
healing by fibrosis.
Intestines
Congenital abnormalities include atresia, stenosis, diverticula and
Hirschsprung’s disease (absence of ganglion cells in the large
intestine (rectum and sigmoid colon).
Malabsorption: The sub optimal absorption of nutrients
(carbohydrates, proteins, fats, vitamins, electrolytes and
minerals) and water. It is classified as due to
Defective digestion: due to deficiency of enzymes
Mucosal cell abnormalities: results in defective terminal
digestion and/or defective transport of the nutrients
Reduced small intestinal surface area: Celiac sprue or
Iatrogenic: post surgical resection
Lymphatic obstruction: due to lymphoma or tuberculosis:
resulting in deficient fat absorbtion
Infections: tropical sprue, parasites, and Whipple’s disease.
The clinical consequences of
malabsorption syndromes
• Alimentary tract: diarrhea, pain, weight loss, passage of bulky,
greasy stools
• Hematopoietic system: causes anemia, bleeding
• Musculoskeletal system: osteopenia and tetany (hypocalcemia)
• Endocrines: amenorrhea, impotence, infertility and
hyperparathyroidism
• Skin: purpura, petechia, edema, dermatitis
• Nervous system: peripheral neuropathy
Idiopathic inflammatory bowel disease
It includes Crohn’s disease and ulcerative colitis
Crohn’s disease is a granulomatous disease affecting any portion of
the gut but most often the small intestine and colon.
Ulcerative colitis is a non-granulomatous inflammatory disorder
involving the colon.
Both the diseases are unexplained (idiopathic) but some
etiological factors are implicated like:
Genetic (familial clustering is noted), infectious agent may be the
cause (as there is inflammation), or abnormal host
immunoreactivity.
Feature Crohn’s disease Ulcerative colitis
Site Throughout the GIT The colon starting from the
rectum
Distribution Skip lesion Continuous lesion
Stricture & Fibrosis Occurs early in the disease Rare/ occurs late as fibrosis
due to marked fibrosis is to a lesser degree
Wall Thickened Thin & Dilated
Ulcers Deep and linear Superficial
Fistulas Present Absent
Pseudopolyps Absent Present
Granulomas Present Absent
Extra intestinal Arthritis, Ankylosing Occur but to a lesser extent
manifestations spondylitis Uveitis,
Cholangitis and Erythema
nodosum
Malignant potential & Definite risk Present but rarer
Prognosis Poor prognosis Good prognosis
Fat & vitamin malabsorption Present Absent
