Thursday, September 23, 2010

7.(0-2) Physician's Notebooks 7/G.I. Pain & Symptom/

Physician's Notebooks 7 - - See Homepage

This section 7.(0-2) contains cover and Chapter 1 of Notebooks 7 on GI tract and renal function. Scroll down further for Chapter 2 on Signs and Symptoms of GI disease and bleeding.
Update 20 December 2018
Physician’s Notebooks
An Old Doc Recommends to a New Generation
Gastrointestinal & Genitourinary
(Chapters hyperlinked to text; click to read now)
PN 1. Introduction to the Gastrointestinal Tract
To help readers go to a topic, use the following table in descending order as it appears in text, to see what's in the 2 chapters and to search & find the topic for short reading.
Chapter 1: Follow food from mouth 
Liver, Gallbladder (GB) & Ducts, and Pancreas & Ducts
Ileum a.k.a. Small Intestine
Colon, a.k.a. Large Intestine
 Diseases: Diarrhea, Appendicitis, Diverticulosis
  Inflammatory Bowel Diseases
Rectum and Anus
Chapter 2: Gastrointestinal Signs & Symptoms  illustration
Stool Appearance
Flatus, or farting
Distended Belly

Chapter 1:

Follow food from mouth: First it goes into the rear throat and  down the esophagus by coordinated muscle contraction. The gastro-esophageal (G-E) sphincter is located where esophagus empties into stomach. When food is not being swallowed, the GE sphincter is closed. It opens to allow food to pass. A frequent esophagus disease, G-E Reflux (GERD) causes chest pain after eating due to weak G-E sphincter.
Because it is exposed to partly chewed food, hot beverage and other trauma it is site of cancer, especially in smoker and drinker. Despite early diagnosis via scope, esophagus cancer has low cure rate because it spreads early. Prevent by chewing food well, reducing amount of hot beverage by allowing it to drop temperature, avoiding cigarette and keeping alcohol intake low and washing down with water after eating and drinking.
After eating, its sphincters shut and for several hours it is a churning mixer. Acid stomach secretion is no problem for stomach because its cells are resistant. But if sphincters are weak, the acid juice refluxes up into esophagus or leaks down into duodenum, and then it makes pain in chest or pain in upper right to mid abdomen from peptic ulcers or irritation gastritis/duodenitis. Aspirin irritates stomach and may cause bleeding.
   Stomach frequently develops cancer but dying from it is now rare because of early diagnosis via scope, and improved early surgery, and treatment with proton pump inhibitor meds (PPI's like Omepral).
Once food is liquefied and partly digested in stomach, it passes into duodenum where pH rises sharply due to alkaline bicarbonate secretion. Duodenum is frequent site of peptic ulcer due to defective sphincter, too high acid (from stomach). And peptic ulcer may bleed.
Liver, Gallbladder (GB) & Ducts, and Pancreas & Ducts
The secretions of liver and pancreas empty into the duodenum, at the sphincter of Oddi and it is a point where a gallstone may get stuck and harm liver and pancreas, causing pain and yellowing skin (jaundice). Nowadays such stones can be removed by endoscope. The liver makes bile, which flows from liver ducts to main bile duct and is sucked up into Gall Bladder (under the right lobe of the liver connected to the liver bile system) via cystic duct, concentrated there, and squeezed out from the common duct into duodenum where it helps the digestion and absorption of fat from food and also gets rid of cholesterol. The pancreas is a mixed organ that produces digestive enzyme-juice which flows to duodenum down the common duct and out the sphincter of Oddi and completes the digestion of fat, protein and carbohydrate in small intestine. Other pancreas cells make insulin, to get glucose into all the cells in the body so it can be burned for energy. Without it diabetes mellitus (DM) develops.
   Emptying of Gall Bladder is a reflex whose button is pushed when liquefied food containing partly digested fat enters duodenum. It concentrates bile so well that bile stone may form, especially in age fifty, fat and femme (3 Fs of gallstone disease). When stone gets stuck in common duct it becomes painful emergency with jaundice.
   The liver is the source of cirrhosis and cancer from drinking ethyl alcohol. Also it gets inflamed in hepatitis due to viruses from contaminated injection or due to food or sex infection, and also from chemical toxins like benzene. Pancreas similarly reacts badly to the alcohol with pancreatitis and cancer. Note that the common duct serves as exit for bile from the liver and GallBladder and also as exit for pancreatic secretion. 
Ileum aka Small Intestine
From duodenum, partly digested food flows through small intestine, where it is digested and its molecules are absorbed (glucose and other mono-sugar, the fat products triglyceride and cholesterol, and protein amino acids) into the blood. The small intestine is the source of much infectious diarrhea like salmonella. It cannot be endoscoped and can only be indirectly viewed by swallowed capsule with video camera and tape.
Colon, aka Large Intestine
Indigestible food residue including fiber is presented to colon, which removes water from the food residue. Friendly bacteria that live off the food residue, and make needed vitamins and not-needed gas, colonize the colon and it is the most frequent site of cancer and diseases described below.
Diseases of the Colon: Diarrhea, Appendicitis, Diverticulosis, Cancer
The appendix starts the colon in your right lower abdomen. An important colon disease, diverticulosis is caused by appendix-like out-pouchings called diverticuli, which may become problem by getting blocked and infected or by hemorrhaging especially from taking aspirin and high blood pressure. Diarrhea is from inflammation of colon and due to germ or chemical in food.
       Inflammatory Bowel Diseases involve small and large (colon) intestines. In small intestine it is Crohn's diease aka regional ileitis; in colon it is ulcerative colitis. Symptoms are mid & low abdominal pains, small bowel obstruction in Crohn's, and bleeding in ulcerative colitis. 
Cancer is frequent in the colon due to slowing down of food, allowing longer time for cancer-causing chemical in food. Because colon is accessible to colonoscope, the colon cancer death is now rather infrequent.
Rectum and Anus
At end of GI tract, Rectum collects and stores stool for expulsion. Its diseases, hemorrhoid and abscess, are caused by excessive straining to expel constipated stool. Rectal cancer is found early by rectal exam with finger and scope but its cure is problematic because surgical removal is complex and early spread frequent. The anus is also called back hole and is sometimes penetrated by an erect penis for sex. It is accessible to examining or treating finger. Its main disease is external hemorrhoid – a blow-out vein from too much pushing to expel stool. 
Chapter 2. Gastrointestinal Signs & Symptoms 

Use Loupe
“Where do you feel pain from the GI tract?” Esophagus pain is a great deceiver. It may be behind breastbone and confused with heart pain; it may strike upper back and be thought to come from the backbones; or it is felt over rib, collarbone, shoulder, or in armpit. When caused by reflux esophagitis, aka GERD, the key is its relationship to body position and timing and content of last meal. Since it is caused by the reflux of stomach acid with partly digested food, it will come in the hours after heavy meal when dozing in chair (Surprisingly in chair more than when lying flat in bed); and it is relieved within minute by drinking cold water after awakening and standing up.
   Stomach pain is in upper right side abdomen and mid abdomen, on eating, either immediately after (food poisoning) or hours later (gastritis).
   Duodenal pain (peptic ulcer) is between navel and right upper abdomen, a gnawing pain that intensifies as minutes pass. It onsets with emptying acid stomach juice into duodenum (worst 3 to 4 hrs after eating) and is quickly relieved by eating or acid neutralizer
   Gall bladder, common bile duct or liver pain is just below right rib margin, provoked by fatty food meal, and with gas and right upper abdomen cramp after eating and, right-side upper abdomen pain and, in case of stuck stone, with yellow skin jaundice.
            Pancreas pain (pancreatitis) is mid upper abdomen, dull but intense and with vomiting. In older person, almost always alcoholism.
Pain in small intestine including appendix is felt at first around navel. If from appendicitis, after several hours it moves down to right lower abdomen at typical point 2/3 along line drawn from navel to right pelvic crest.
   Colon pain is located below navel over part of area involved and is a sharp, severe, cramping, alternating with a pain-free period over a 1- or 2-minute cycle (“colic”). Left colon pain typically precedes and is relieved by bowel movement.
   Rectum and anus pain is local but also from organ connected to rectum: uterus, tubes and ovaries in women, prostate in men, especially during need to urinate.
Vibratory and sometime noisy passage of gas from stomach up through esophagus. If it tastes or smells bad, it is from rotten food. Persons with hiatus hernia, experience a low-pitch rumble in mid chest due to incomplete closure of G-E sphincter.
Timing localizes source. From esophagus it is shortly after swallowing, and it is more, ‘regurgitation’. Within few hours after eating the vomit will be watery, brownish stomach juice and partly digested food with acid smell. With more vomiting, food is replaced by yellow bile fluid. Presence of bile in vomit confirms a well functioning Gall Bladder; its absence in clear fluid vomit may mean GB disease.
   From duodenum, several hours after eating, the vomit resembles stomach content. Pattern of delayed vomiting several hours after eating suggests cancer, usually pancreas that is compressing duodenum.
   With upper GI bleeding, vomit looks like coffee grounds but if bleeding is rapid and heavy it may be bright or darker red.  
   From small intestine or colon, vomiting is late sign of obstruction and patient appears chronically ill and has several day history of painful, swollen abdomen. Vomit from low down in the GI tract smells and looks like loose feces.
is liquid or loose stool produced in runs preceded by cramps. When mixed with small amounts of blood it is “dysentery” due to infection. When diarrhea has emptied intestine, the bowel movement takes on appearance of clear mucous. Most infectious diarrhea is due to infectious virus in food. Another common cause is due to chemical or natural laxative in food (nitrite in hot dog, too much artificial sweetener, an over-ripe mango). Such diarrhea is obvious from the brief time after eating and consists of 1 or 2 cleansing, satisfying bowel movements. When diarrhea has small amount of blood, it suggests salmonella, am(o)eba, giardia or other intestinal parasite infection and is usually with abdominal discomfort and sometimes fever. Diarrhea lasting more than several days suggests inflammatory bowel disease like regional ileitis or ulcerative colitis but may also be due to chronic infection or food hypersensitivity like gluten.
Bad diarrhea may be caused by antibiotic that kills off friendly germ in colon and allows bad bacteria to take over. It is hard to cure quickly and has sizable death rate. It is reason not to take oral antibiotic longer than 6 days.
should be considered the un-easy passage of harder than normal stool with straining and pushing. One cause of bad constipation is ingestion of calcium pills which "concretize" stools. Infrequent stool is also caused by opioids like codeine that slow stool passage through the intestines. Constipation may be caused by food that is processed to remove fiber and is seen in strict vegetarians who bread-fry mushrooms to resemble meat or in persons subsisting on pizza. Occasionally, constipation may be caused by poorly formed stool that has a mucky consistency. An approach to problematic constipation is to suspect pills you take regularly and if you cannot discontinue the constipating source at least eat much fresh fruit and vegetable, especially mango and blueberries. Bananas 3 or 4 a day will soften stool but if you eat too many bananas a day, it will increase triglycerides in your blood. Drinking a liter of water at once makes constipated bowels move within the hour.
Never strain strongly at stool. If you are doing it, stop and try to pass the stool later. Stool in rectum can wait and no problem. My experience shows me that one can normally go up to three days without a bowel movement and not be bothered at all. After three days, constipation should be considered a problem to be dealt with by the remedies given here. Many of us sit to stool on schedule. One should wait till one gets a feeling of stool in rectum before sitting. Immediately, on passing stool, often another stool is right on way into rectum, and getting up to walk up and down a minute and then sitting down hard on the toilet seat will bring the stool down. Also press down deeply with hand into the left lower abdomen just above pubis. And with very difficult stool use lubricated finger into the anus-rectum to check that stool is actually low in the rectum and to dislodge or break it up.
Stool Appearance
Clay-like gray or white stool is early sign of soon-to-come skin jaundice from liver or Gall Bladder disease. When you see it, look to your urine for deepening brown color and at whites of eyes for early yellowing. Jet-black stool can be due to eating iron pill or drinking Pepto Bismol  but if you are not taking either one, suspect bleeding from ulcer or cancer high in GI tract (esophagus, stomach, duodenum or small intestine). Currant-jelly-like reddish stool is sign of bleeding high in colon from cancer or diverticulosis while blood-covered, otherwise normal stool is sign of bleeding in rectum often from hemorrhoid but may be cancer. The common red blood on toilet paper right after hard BM is due to local trauma from straining at hard stool. Any heavy rapid GI hemorrhage gives red bloody stool.
Flatus, or farting
is sign of healthy bowel; it should not be suppressed but also not allowed to be obvious to nearby persons. Bad smelling flatus is due to food (oyster or spiced meat the worst offender). Closely related to flatus is intestinal gurgle, which may be normal but which, if frequent, loud, with cramp, and not followed by Bowel Movement, is early sign of intestinal obstruction.
Distended Belly
usually comes from over-eating but if you are an alcoholic, suspect liver cirrhosis or early cancer. Spreading cancer to liver distends the belly with fluid. A woman who gets a distended belly and, if young, is pregnancy test negative, usually has uterine fibroid tumor or big ovary cyst, and an abdominal ultrasound scan will reveal it. Sudden distended belly with gurgling, pain and no BM is acute intestinal obstruction.
End of Chapter 2, Physician's Notebooks 7. To read next now, click 7.3 Splenectomy - Leukemia Cure/Liver/Pancreas

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