1. DISORDERS/ AND OR ADVERSE REACTIONS - ALIMENTARY SYSTEM-  -                                                                           SUMMARY

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Contents

1.Evidence Based Medicines                                                                               i.Gastro-Oesophageal Reflux Disease

2.Facts on Finger Tips                                                                                                         i. Constipation                                                                                                                      ii.Ulcerative Colitis                                                                                                              iii. Crohn's Disease                                                                                                            iv. Primary Biliary Cirrhosis

3. Disorders and/or Adverse reactions -                                                                              Items 1 to 27

 
                        Evidence Based Medicine (MIMS- March 2003)

FACTS ON FINGER TIPS

4.PRIMARY BILLIARY CIRRHOSIS

Salient Features-  (MIMS) 

 1. About 90 percent of cases occur in women                                                                       2. Peak age of onset is between 30 and 60 years                                                                 3. Condition is probably due to autoimuune disease                                                         4. Can be associated with thyroid diease, Sjogrens syndrome, coeliac disease,                   CREST  syndrome, hepatic and extra-hepatic malignancy and pancreatic                         hyposecretion

Clinical featutes

 1. The earliest stage is chronic nonsuppurative  destructive cholangitis                              2. Tiredness and pruritus                                                                                                      3. Jaundice                                                                                                                           4. Enlargement of liver and spleen                                                                                      5. Half of the patients asymtomatic at presentation                                                              6. Dry eyes and mouth                                                                                                          7. Steatorrhoea                                                                                                                      8. Easy brusing due to Vitamin  K deficiency

Investigations

 1.  Liver  finction tests , Liver enzymes are deranged                                                           2.  Clotting screen: anabnormal clotting profile is indicative of advanced disease           3.  Increased levels of aAlkaline Phosphotase                                                                     4.  Autoimmune screen: affected have positiveanti-microchondrial anibodies                   5.  Liver biopsy cinfirms diagnosis

Management                                                                                                                         1.  Symptomatic treatment of pruritus                                                                                   2.  Patient should be supervised by a  gastroerloogist or hepatologist                               3.  Supplementation with fat soluble vitamins                                                                   4.  Patients with advanced disease or intractable symptoms may have a liver transplant

Key Points

 1.  Without  a transplant, most patients do not survive more than 10 years                       2.  Patients  are at increased risk of hepatacellular carcinoma                                            3    Deficiencies in the fat souble  Vitamin A ,D and K may occur, resulting in                           osteomalacia and coagulation defects                                                                       4.   Jaundice may be a late feature

1.DISORDERS/ AND OR ADVERSE REACTIONS - ALIMENTARY SYSTEM- SUMMARY
 
    ( Ref- Harrisons - Priniciples of Internal Medicine Ninth Edition )

1. Indigestion ( 194 ).
2. Heartburn ( 196 )
3. Dysphagia (192 )
4. Flatulance  ( 201 )
5. Anorexia    (197 )
6. Nausea, Vomiting and Retching (197 )
7. Gastritis  ( 1388 )   
8. Diarrhea and Constipation (199 )
9. Irritable bowel syndrome (201 )
10. Gastrointestinal Reflux ( 1366 )
11. Reflux Oesophagitis ( 1367 )
12. Peptic Ulcer - Zollinger- Ellison Syndrome ( 1371 )
13. Duodenal Ulcer ( 1373 )
14. Gastric Ulcer ( 1377 )
15. Dental Discoloration ( 387 )
16. Gingival hyperplasia ( 387 )
17. Oral ulceration ( 387 )
18. Taste disturbances ( 387 )
19. Dry mouth  ( 387 )
20. Swelling of salivary glands ( 388 )
21. Peptic ulceration or hemorrhage (1370)
22. Intestinal ulceration ( 388 )
23. Malabsorption ( 388 )
24. Pancreatitis ( 1503 )
25. Diffuse hepatocellular damage ( 388 )
26. Cholestatic jaundice ( 209 )
27. Periodontal Disease- (187)
      
1. Indigestion ( 194 )

Indigestion is a term frequently used to describe a multitude of symptoms                           generally appreciated with the distress with the intake of food. To some                     patients indigestion refers to a feeling that digestion has not proceeded naturally.

They may describe a sense of abdominal fullness, pressure or actual pain. Others         may use the term to describe heartburn, belching, distention or flatulence.
Indigestion may occur as a result of disease of the gastrointestinal tract or in       association with pathologic states in other organs      

2. Heartburn ( 196 )

Heartburn or pyrosis is a sensation of warmth or burning located substernally                     or high in the epigastrium. Experimental studies in human beings have shown that esophageal distention or  increased motor activity is associated in most subjects            with a feeling of fullness and burning  in this area.

Heartburn may occur with organic disease of the intestinal tract and is usually       associated with gastroesophageal reflux. This is frequently the case in hiatus hernia

3. Dysphagia (192 )

Dysphagia or difficulty in swallowing is a most reliable symptom and indicates                  the presence of disease or dysfunction.  Dysphagia should never be dismissed as emotional disturbance or to be confused with globus hystericus, a term used to          indicate the sensation of a lump or tightness in the  throat independent of swallowing
 
4. Flatulance  ( 201 )   

A significant amount of flatus is passed each day by normal persons and the complaint of flatulence often reflects a heightened and embarassing awareness of this natural occurence. Many who  complain of gas are in reality experiencing symptoms as describable to disordered motility. Excessive passage of  intestinal gas may be the result of aerophagia or the formation of  increased amounts of gas by intestinal bacteria.

 5. Anorexia    (197 )

Anorexia or loss of the desire to eat is a prominant symptom in a wide variety of intestinal and extraintestinal disorders. Anorexia occurs in many disorders and as a result by itself or of little specific diagnostic value. The mechanism whereby hunger and appetite are modified in various diseases are poorly understood. Anorexia is commonly seen in diseases of the gastrointestinal tract and the liver.
 
6. Nausea, Vomiting and Retching (197 )

Nausea and vomiting may occur independently of each other, but generally they are so closely allied that they may conveniently be considered together. Nausea denotes the feeling of imminent desire to vomit,usually referred to the throat or epigastrium.
Vomiting  refers to the forceful oral expulsion of gastric contents.

Retching denotes the labored rhythmic respiratory activity that frequently precedes emesis.
Nausea often precedes or accompanies vomiting. It is usually associated with diminished functional activity of the stomach and alterations of the motility of the duodenum and small intestine.

   Adverse Reaction - Drugs ( 388)
    1. Digitalis
     2. Opitates
     3. Estrogens
     4. Levodopa
     5. Potassium cholride
     6. Ferrous sulphate
     7. Aminophylline
     8. Tetracyclines 

7. Gastritis  ( 1388 )   

Gastritis may be associated with recent alcohol ingestion or with the use of anti-inflammatory drugs,such as aspirin or indomethicin. Another frequent setting is the development of gastric erosions in stressful situations such as following major trauma or surgery or in assocaition with severe systemic  disease. The occurence of gastritis in burn victims and patients with increased intracranial pressure  is also common.

8. Diarrhea and Constipation (199 )

The bowel habits of apparently healthy persons vary widely. For this reasoon, the term diarrhea and  constipation have most meaning when viewed as a change from an individuals customary pattern.  Reasonably detailed information is important in evaluating either abnormality.When  patients complain of diarrhea, it is important to obtain an estimate of the volume as well as frequency of fecal output and in addition, to directly examine a stool for consistency, blood,
oilness and malodor.

The term constipation may be used by the patient to a variety of changes including reduction in frequency of defecation, a constant sensation of rectal fullness and incomplete evacuation of faeces and sometimes painful defecation due to hard stools or perianal pathology

 Diarrhea or colitis ( 388 )
    Adverse Reaction - Drugs
     1. Lincomycin
     2. Clindamycin
     3. Broad spectrum antibiotics
     4. Magnesium in antacids
     5. Guanethidine
     6. Debrisoquin
     7. Metyldopa
     8. Reserpine
     9. Digitalis
     10. Colchicine
     11. Purgatives
     12. Lactose excipents

  Constipation or ileus ( 388 )
    Adverse Reaction - Drugs
     1. Ganglionic blockers
     2. Tricyclic antidepressants
     3. Phenothiazines
     4. Opiates
     5. Aluminuim Hydroxide
     6. Calcium carbonate
     7. Barium sulphate
     8. Ion exchange resins
     9. Ferrous sulphate

 9. Irritable bowel syndrome (201 )         

The irritable bowel syndrome (also referred to as spastic colon and mucous colitis ) is one of the most frequent gastrointestinal disorders. This condition is chracterized by periodic or chronic symptoms of diarrhea, constipation and abdominal pain. These symptoms are generally associated  with psychologic stresses, but the anxiety produced by the bowel disturbance is sometimes regarded  by the patient as the fundemental cause of emotional upset.Stools tend to be thin, fragmented or pelletlike and accompanied by excessive mucus and gas.

10. Gastrointestinal Reflux ( 1366 )

Reflux of small amounts of gastric juice into the lower part of the esophagus is a common event. Its frequency is increased by over indulgence. Whether reflux occurs and whether it produces symptoms are determined by three factors
1. the competency of the lower esophageal sphincter , the primary barrier to reflux
2. the irriatant nature of the refuxed material and
3. the sensitivity of the esophageal mucosa to the refluxed material
Although the symptoms of reflux were attributed  in the past to inflammation of the esophagus  ie. esophagitis. It is clear that esophagitis is a complication of severe reflux rather than the cause of the symptoms  associated with reflux.

11. Reflux Oesophagitis ( 1367 )

Reflux esophagitis is inflammation of the esophageal mucosa caused by reflux of acid gastric or alkaline intestinal juice. Esophagitis is the prcursor of the complications of reflux, namely,bleeding, stricture and change in esophageal epithelium from squamous to columnar. Bleeding is slow and chronic. Acute massive bleeding occassionally occurs with esophagitis but is usually due  to an associated peptic ulcer of the esophagus.

12. Peptic Ulcer - Zollinger- Ellison Syndrome ( 1371 )

Peptic ulcer is a term used to refer to a group of ulceratrive disorders of the upper gastrointestinal tract, which appears to have in common the participation of acid pepsin in their pathogensis. The major forms are chronic duodenal and gastric ulcer. The Zollinger-Ellison syndrome gastrinome may also be considered a form of peptic ulcer.

13. Duodenal Ulcer ( 1373 )

Duodenal ulcer is a chronic and recurrent disease. The ulcer is usally deep and sharply demarcated.It tends to penetrate through the submucosa and often into the muscularis propria. The ulcer floor contains no intact epithelium and usually consists of a zone of eosinophilic necrosis resting on a base of granulation tissue surrounded by variable amounts of fibrosis. The ulcer bed may be clear or contain either blood or a proteinaceous exudate with entrapped erythrocytes and acute and chronic
inflammatory cells.

 14. Gastric Ulcer ( 1377 )

Gastric ulcers, just like as duodenal ulcers, are more common in males. They are also histologically similar to duodenal ulcers. Gastric ulcers are characterstically deep, extending beyond the mucosa of the stomach. Almost all benign gastric ulcers are located in the antrum, in a zone immediately distal to the junction of the antral mucosa with the acid-secreting mucosa of the body of the stomach.

15. Dental Discoloration ( 387 )

      Adverse Reaction - Drug 
      1. Tetracycline

16. Gingival hyperplasia ( 387 )

     Adverse Reaction - Drug 
     1. Phenytoin

17. Oral ulceration ( 387 )

    Adverse Reaction - Drugs
     1. Aspirin
     2. isoproternol ( sublingual )
     3. Cytotoxics
     4. Pancreatin
     5. Gentian Violet 

18. Taste disturbances ( 387 )

   Adverse Reaction - Drugs
     1. Penicillamine
     2. Biguanidines
     3. Griseofulvin
     4. Metronidazole
     5. Lithium
     6. Rifampicin

19. Dry mouth  ( 387 )

    Adverse Reaction - Drugs
     1. Anticholinergics
     2. Levodopa
     3. Tricyclic antidepressants
     4. Clonidine
     5. Methyldopa

20. Swelling of salivary glands ( 388 )

    Adverse Reaction - Drugs
     1. Phenylbutazone
     2. Guanethedine
     3. Bethanidine
     4. Bretylium
     5. Clonidine
     6. Iodides

21. Peptic ulceration or hemorrhage ( 1370)

Peptic ulcer is a term used to refer to a group of ulcerative disorders of the upper gastrointestinal tract, which apperas to have in common the participation off acid-pepsin in their pathogenesis. The major forms are chronic duodenal ulcer and gastric ulcer. The Zolinger- Elison syndrome (gastronoma ) may also be considered a form of peptic ulcer.

    Adverse Reaction - Drugs
      1. Aspirin
      2. Phenylbutazone
      3. Indomethicin
      4. Ethacrynic acid  ( large doses )
      5. Reserpine  large doses )

22. Intestinal ulceration ( 388 )

   Adverse Reaction - Drug
     1.  Enteric coated potassium chloride

23. Malabsorption ( 388 )

    Adverse Reaction - Drugs
     1. Broad spectrum antibiotics
     2. Neomycin
     3. Cholestyramine
     4. Colchicine
     5. p-Aminosalicylic acid
     6. Biguanides
     7. Phenytoin
     8. Primidone
     9. Phenobarbital
     10. Cytotoxics

24. Pancreatitis ( 1503)

Pancreatic inflammatory disease may be classified                                                               1. acute pancreatitis, 2.relapsing acute pancreatitis, 3. relapsing  chronic pancreatitis            and 4. chronic pancreatitis.

There are many causative factors in the pathogenesis of acute pancreatitis, but the mechansm by which these conditions trigger pancreatic inflammation have not been identified. Alcoholicpatients with pancreatitis may represent a special subset, since most alcohilic do not develop pancreatitis. The list of identifiable cause is growing, and it is likely that a pancreatitis related to viral infection and drugs are more common than therefore recognized
 

   Adverse Reaction - Drugs
     1. Corticosteroids
     2. Thiazides
     3. Azathioprine
     4. Oral contraceptives
     5. Sulfonamides
     6. Opiates
     7. Furosemide
     8. Ethacrynic acid

25. Diffuse hepatocellular damage ( 388 )

  Adverse Reaction - Drugs
    1. Halothane
    2. Methoxyflurane
    3. Methyldopa
    4. Isoniazid
    5. Rifampicin
    6. Amino salicylic acid
    7. Ethionamide
    8. Phenytoin and other hydantoin
    9. Acetaminophen ( paracetamol )
    10. Salicylates
    11. Allopurinol
    12. Sulfonamides
    13. Tetracyclines
    14. Erythromycin estolate
    15. Propythiouracil
    16. Methimazole
    17. Oxyphenisatin
    18. Methotrexate
    19. Pyridium
    20. Propoxyphene
    21. Monamine oxidase inhibitors

26. Cholestatic jaundice ( 209 )

A patient may be described as having obstructive or cholestatic jaundice. By this is meant that clinically,  and especially biochemically , there is little to suggest hepatocellular damamage and that main features point out to interference with, or obstruction  in, the flow of bile

   Adverse Reaction - Drugs ( 388 )
    1. Phenothiazines
    2. Androgens
    3. Anabolic steroids
    4. Oral contraceptives
    5. Erythromycin estolate
    6. Chlorpropamide
    7. Gold salts
    8. Methimazole
    9. Acetohexamide

27. Periodontal Disease- (187)

 Periodontal disease begins as a marginal inflammation of the gingivae ( gingivitis )which slowly  spreads to invove the underlying aleveolar bone and priodontal ligament. As the disease  progresses the aleveolar bone is reabsorbed , resulting in loss of periodontal ligament fiber  attachment from the tooth to the bone. The separation of of the soft tissue from the tooth surface  results in - pockets- formation, the inner aspect of which bleeds readily on probing or spontaneously  during chewing.