Disorders of GI Secretions - Salivary/Gastric

  1. Salivary secretions are protective - physical and antibacterial
  2. Physically protective - acts as a buffer for acid/base, heat/cold, resist abrasion
  3. Bicarbonate and epidermal growth factor promote healing (to esophagus)
  4. Lysozyme and IgA inhibit bacterial growth and bacterial attachment
  5. Neural reflex responses are elicited by sensory (cephalic), feeding, oral stimuli, and oral/alimentary irritation through the duodenum
  6. Neurotransmitter effects
    • PNS - Acetylcholine stimulates secretions
    • SNS - Norepinephrine inhibits secretions (except mucus)
    • PNS - Vasoactive intestinal peptide (VIP) increases blood flow
  7. Mucoceles - dry mouth disorder that is harmless, presents as a moveable and pearly cyst, caused by damage to the minor salivary ducts. Usually heals on its own.
  8. Diseases of the salivary glands can alter the chemical composition and amount of saliva produced
  9. Stress inhibits PNS stimulation of salivary secretion, leads to dry mouth
  10. Dry mouth frequently causes complaints of dysphagia, altered taste, dental caries, and is caused by Sjogren's syndrome, sysemtic amyloidosis, radiation injury
  11. Radiation-induced xerostomia - can lead to xerostomia, glossitis, widespread caries
  12. General treatment of xerostomia
    • Mouthwashes - artificial saliva with bicarbonate and antibiotics, saline, water
    • Salivary stimulates - sensor reflexes, PNS stimulants (Pilocarpine)
    • Other options - coating agents, antibiotics, topical anesthetics
  13. Sjogren's Syndrome
    • Systemic autoimmune disease that attacks the body's immune system and targets the salivary and tear glands
    • Reduction in saliva and tear production
    • Dry mouth and dry eyes are primary symptoms - irritation and grittiness can occur
    • Difficulty chewing and swallowing
    • Inflammatory or cancerous conditions of the salivary glands can also affect levels of IgA, which helps reduce the incidence of oral infections after minor injuries and scrapes of the oral mucosa
    • Dry eyes - xeropthalmia
    • Virtually all organs may be involved - Swollen salivary glands, glossitis, thrush, severe caries, xeroderma (dry skin) with chelitis, erythema, GERD, esophageal dryness, urticara and/or purpura, nasal/vaginal dryness
    • Schirmer test for salivary flow
    • Mainly autoimmune, 9x as likely in women and 87% have HLA-DR52 serotype
    • Can be triggered by viruses - also associated with radiation, neuropathy, drugs, etc.
    • Related to rheumatoid arthritis, myalgia, Raynaud's phenomena, vasculitis, pericarditis, leukopenia, anemia, lymphoma, etc.
    • Antigens directed against glandular material
      • Antigen B (SSB) - 42% sensitivity, 83% specificity, binds protein that upregulates micro RNA
      • Antigen A (SSA) - 56% sensitivity, 42% specificity
      • Juvenile form positive for anti-alpha fodrin antibody, also less specific antigens (anti-Rh, anti-nuclear)
    • Other tests - salivary flow measured by sialography; biopsy revealing lymphocytosis with CD4+ predominance; biopsy for lymphoma, granuloma, sarcodiosis, etc.; CBC, creatinine
    • Treatment - No definitive treatment
      • Cyclophosphamide
      • Lemon drops/artificial saliva, Pilocarpine or Cevimeline
      • Artificial tears
      • Hydroxychloroquinone, Prednisolone if anular erythema present
      • NSAIDs for pain
      • Advanced meds - IFN-alpha, Rituximab
      • AVOID anticholinergics (antihistamines)
  14. Mumps
    • Acute viral disease with swelling and inflammation of the parotid gland caused by paramyxovirus
    • Fever, loss of appetitie, weakness, discomfort - swelling of parotid gland, spasm of the jaw muscles, pain when mouth is open or during mastication
    • In adults it is often more severe
    • Can affect other tissues, including the joints, pancreas, myocardium, kidneys
  15. Gastritis and Peptic Ulcer Disease (PUD) caused by overproduction of gastric acid and/or damage to mucosal protective barriers
  16. Gastric mucosal barrier keeps pH of cell surface at 7 despite gastric juice pH of 1 to 2
  17. Gastritis
    • Acute or chronic
    • Acute gastritis can be caused by NSAIDs (erosive gastritis - due to inhibition of mucus-producing prostaglandins), alcohol, histamine, metabolic disorders (uremia), H. pylori
    • Acute presents with burning epigastric distress and is diagnosed with thick folds, inflammatory erosions, nodules
    • Chronic gastritis can be caused by H. pylori, Crohn's disease, chronic exposure to NSAIDs or alcohol, may be autoimmune
    • Chronic is diagnosed with endoscopy and biopsy, complications include fat, iron, vitamin B12 malabsorption
    • Chronic gastritis is a risk factor for gastric carcinoma and pernicious anemia
  18. Peptic Ulcers are caused by high acid and peptic content, irritation, poor blood supply, poor secretion of mucus, or infection by H. pylori
  19. Duodenal ulcer - a deep ulceration in the duodenal wall extending as a crater through the entire mucosa and into the muscle layers
  20. H. pylori usually present in both gastrifc and duodenal ulcers
  21. Gastric ulcers usually onset at a higher age than duodenal ulcers
  22. Serum pepsinogen increased in duodenal ulcers, gastrin increased in gastric ulcer
  23. Duodenal ulcers tend to experience remission
  24. Peptic - affiliated with digestion (stomach, intestines)
  25. Zollinger-Ellison syndrome may be associated with PUD - consequence of gastrin-secreting tumor causing gastric hypersecretion and alimentary hyperplasia - ulcerations occur past the pylorus
  26. Stress/serious illnesses can cause PUD; acute ulceration may occur from mechanical causes or gastritis
  27. PUD may indicate gastric cancer
  28. PUD persistence may indicate malignancy
  29. PUD treated with endoscopic surgery for bleeding, vagotomy (refractory) or gastroectomy (severe/cancerous cases)
  30. Upper GI bleeding often caused by peptic ulcers, lower GI bleeding caused by polyps, inflammatory disease, cancer, hemorrhoids, diverticulitis