1! SYDNEY MEDICAL PROGRAM SMP2014 LEARNING TOPICS Stage 2 BLOCK 9: Gastroenterology and Nutrition Copyright © 2014 Sydney Medical Program, University of Sydney Compiled by P. Romo and S. Hewson for SUMS 2! CONTENTS • 9.01 – A persistent pain // Peptic ulcer 3 1. Upper gastrointestinal structures 4 2. Upper gastrointestinal motility 5 3. Vomiting 6 4. Gastric secretion 7 5. Causes of upper gastrointestinal bleeding 10 6. Complications of non-steroidal anti-inflammatory drugs 11 7. Early treatment of peptic ulcer 13 8. Medical evaluation in the aged 15 • 9.02 – I’m not a hundred per cent // Coeliac disease 16 1. Function of exocrine pancreas 17 2. Digestion 19 3. Nutrient absorption and transport 20 4. Nutritional approaches to GI disease 21 5. Vitamin and trace metal absorption 24 6. Mechanisms of diarrhoea 25 7. Mucosal immunity 26 8. Spectrum of coeliac disease 27 • 9.03 – Small and sickly // Failure to thrive in infancy 28 1. Normal nutrition in the first 12 months 29 2. Protein-energy malnutrition 31 3. Lactose intolerance 33 4. Understanding failure to thrive 34 5. Causes of diarrhoea 36 6. Management of acute diarrhoea 38 7. Infectious diarrhoea 41 8. Large bowel function 43 • 9.04 – My eyes look yellow // Gallstones 44 1. Bile secretion 45 2. Composition and formation of gallstones 46 3. Mechanisms of abdominal pain 48 4. Psychosocial issues in care of the older person 50 5. Therapeutic options in biliary disease 52 6. Antibiotic treatment in abdominal sepsis 54 • 9.05 – My pain is getting worse // Liver disease/Hep B 56 1. Liver: blood supply and drainage 57 2. Metabolic functions of the liver 59 3. Pathology of liver disease 60 4. Hepatitis B virology, clinical features and epidemiology 61 5. Tests of liver disease 64 6. Chronic hepatitis and cirrhosis 66 7. Principles of management of liver disease 67 • 9.06 – The good life // Decompensated alcoholic liver disease 69 1. Chronic hepatitis and cirrhosis 70 2. Causes and consequences of liver failure 71 3. Drugs that adversely affect the liver 72 4. Tumours of liver and biliary tract 74 5. The impaired doctor 75 3! 9.01 – A PERSISTENT PAIN // PEPTIC ULCER Learning objectives Anatomy ! (/ Surgery) The clinical aspects of anatomy of the upper regions of the abdomen ! The anatomy and histology (and embryology) of the upper GIT structures (eg, liver, stomach, duodenum) ! (/ Radiology) The anatomical structures from images of the abdomen and pelvis Histology ! To recognise histological features of the mucosa of the oral cavity, including the tongue; to know the definitive histological features of parotid, submandibular and sublingual salivary glands; to know the four histological layers of the alimentary tract (mucosa, submucosa, muscularis externa and serosa or adventitia); to be able to identify the 4 histological layers in the oesophagus, including the features unique to the osophageal wall ! To be able to identify the general layers of the wall of the GIT and their components (mucosa, submucosa, muscularis externa and serosa/adventitia); to be able to differentiate between the 4 different types of papillae on the dorsal surface of the tongue and their associated taste buds; to describe the histology (morphology, microscopic structure and appearance) of the wall of the oesophagus, fundic stomach, duodenum, large intestine, liver, gallbladder and pancreas; to be able to differentiate small from large intestine based on their appearance in light microscope sections; to be able to relate structure to function (eg. Type of epithelium, orientation of the smooth muscle, specific cell types and their location) with the GIT. Gastroenterology • (/ Emergency Medicine) The treatment and management of peptide ulcer and the role of Helicobacter pylori • (/ Pathology) The major causes of upper gastrointestinal bleeding • (/ Surgery) The clinically relevant gross anatomy of the GIT and abdomen. How imaging and endoscopy is used to examine the GIT and abdomen • The ways in which the gastro-intestinal mucosa is protected from the potentially damaging environment in which it exists. The repair processes which also maintain mucosal function Physiology ! The significance and mechanisms of vomiting ! The normal patterns of gastrointestinal motility and symptoms and upper gastrointestinal sensorimotor dysfunction ! The different types of gastric cells and their functions; understand the mechanisms of regulation of gastric acid secretion ! (/ Gastroenterology) Describe the various functions of epithelia within the gastrointestinal tract. Explain the roles of gastrointestinal epithelia in modifying the composition of contents of the gut lumen, transporting nutrients from the gut lumen, and modifying the composition of the milieu interieur Infectious Diseases • To understand that a bacterial infection is the key aetiological factor in peptic ulcer disease and that this has revolutionized the understanding of peptic ulcers and dramatically changed clinical management Behavioural • The proper assessment of an elderly person and the importance of a multidimensional holisitic Science approach Pharmacology • The major complications of non-steroidal anti-inflammatory drugs, in particular gastrointestinal disturbances, renal effects, drug interactions, and cardiovascular effects of COX 2 inhibitors Surgery • The pathophysiology, clinical features, investigations and management of complicated, benign peptic ulcer disease Medicine • Demonstrate the ability to carry out a complete examination of the gastrointestinal system and report on the findings • Demonstrate ability to take a history of gastrointestinal symptoms; demonstrate an understanding of the principles of taking a dietary history and the links between diet and gastrointestinal and other disorders • Reasons for insertion of tubes, the method of insertion and complications in the use of NG tubes Nutrition • To understand the importance and role of macronutrients in the diet; to understand what Australians are eating and its effects; to understand how to change eating patterns to help manage or prevent disease Embryology • The major features and events regarding the early development of the gastrointestinal tract Humanities • Develop a database search strategy for a clinical question using PICO; identify appropriate study designs to answer your clinical question; search the EBM literature using the Cochrane Library via Wiley and Best Practice via BMJ; use EBM limits to define your search results; access search results in full text and save your search 9.01 – A persistent pain // Peptic ulcer 4! 1. Upper gastrointestinal structures I. ANATOMY The visceral relationships of the upper abdominal cavity are much more complex than that of the lower abdominal cavity. In general, the kidneys and suprarenals are the most posteriorly placed organs; in front of these lie gastrointestinal structures. It is important to have an appreciation of how the upper abdominal organs relate to each other to understand the signs and symptoms of pathology of one of these organs. For example, what neighboring structures are affected by a peptic ulcer, an inflamed gallbladder or cancer of the head of the pancreas? The liver lies most anteriorly in the upper abdominal cavity, with its greatest mass to the right. It crosses to the left and lies in front of the upper part of the stomach. The oesophagus is deeply placed and passes into the abdominal cavity just to the left of the midline, coursing for only 1-3 cm before expanding as the stomach. The stomach is mobile and free to move, due to its peritoneal attachments (the lesser and greater omenta) and an extension of the peritoneal cavity behind the stomach called the lesser sac or omental bursa. In contrast, the duodenum is relatively fixed by peritoneum to posterior structures; only its first few centimeters are mobile. The small intestine distal to the duodenum (ie. jejunum and ileum) are again free to move being suspended by 'the mesentery'. Note that the immobile part (duodenum) is the part receiving ducts from the pancreas and gallbladder/liver. It is closely related to all three structures. The duodenum rests partly on the right kidney, IVC and aorta. Various ducts (bile) and vessels (arteries and veins) pass in front and behind its transversely oriented parts. Due to the rotation of the gut during early development, the transverse colon becomes suspended from the front of the duodenum and pancreas, by a peritoneal structure called the transverse mesocolon. The transverse colon and mesocolon separate the liver, stomach and spleen above from the mobile parts of the small intestine below, creating what are called the supracolic and infracolic compartments of the peritoneal cavity. Together with the transverse mesocolon, the apron-like greater omentum helps to retain the very mobile jejunum and ileum and limit their upward extension into the supracolic compartment. To appreciate the relationships of upper abdominal organs, refer to your atlas. Note in particular, the artery passing behind the first part of the duodenum, which may be eroded by a duodenal ulcer. A perforating ulcer of the stomach may release digestive juices into the lesser sac or erode into structures of the 'stomach bed' which include arteries. Erosion of major arteries (eg splenic, gastroduodenal) will cause massive haemorrhage. II. HISTOLOGY OF STOMACH AND DUODENUM The walls of the alimentary tract comprise the mucosa, submucosa, muscularis externa, serosa, and adventitia. Nerve plexuses (actually parasympathetic ganglia) are found in both submucosa