4 December 2012 Introduction to the alimentary system T he burden of GI diseases Professor Julian Walters Gastroenterology Overview The organs of the alimentary tract Symptoms and signs ID: 1047876
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1. Graduate EntryTuesday 4 December 2012Introduction to the alimentary systemThe burden of GI diseasesProfessor Julian WaltersGastroenterology
2. OverviewThe organs of the alimentary tractSymptoms and signs What are the main diseases of the GI tract and liverThe economic burden of GI and liver diseases
3. Organs of the Alimentary SystemMouth and OesophagusStomachDuodenumLiverBiliary systemPancreasSmall intestine duodenum, jejunum & ileumLarge intestinecolon, rectum & anus
4. Functions of the Alimentary SystemDigestion of foodAbsorption of nutrientsMotility from mouth to anusBarrier Immunological EndocrineMetabolic
5. GI tractHistoryExamination
6. Symptoms of Digestive DiseasesGeneralUpper GI TractLiver & BiliaryMid GI Tract & PancreasLower GI Tract
7. Symptoms of Digestive DiseasesGeneralAnorexiaWeight lossAnaemiaUpper GI TractLiver & BiliaryMid GI Tract & PancreasLower GI Tract
8. Symptoms of Digestive DiseasesGeneralUpper GI TractHaematemesis and MelaenaNausea & vomitingDysphagia, odynophagiaHeartburn, acid regurgitation & belchingChest pain Epigastric painLiver & BiliaryMid GI Tract & PancreasLower GI Tract
9. Symptoms of Digestive DiseasesGeneralUpper GI TractLiver & BiliaryRUQ pain Biliary ColicJaundiceDark Urine / pale stoolAbdominal distension (Ascites)Mid GI Tract & PancreasLower GI Tract
10. Symptoms of Digestive DiseasesGeneralUpper GI TractLiver & BiliaryMid GI Tract & PancreasAbdominal painDiarrhoea / steatorrhoeaDistensionLower GI Tract
11. Symptoms of Digestive DiseasesGeneralUpper GI TractLiver & BiliaryMid GI Tract & PancreasLower GI TractAbdominal painBleedingConstipationDiarrhoeaIncontinence
12. Signs of Digestive DiseasesGeneralCachexiaObesityLymphadenopathyAnaemiaJaundiceStigmata of chronic liver diseaseHandsAbdomenAnus & Rectum
13. Signs of Digestive DiseasesGeneralHandsKoilonychiaLeuconychiaClubbingPalmar erythemaDupytrens contractureTremorTachycardiaAbdomenAnus & Rectum
14. Signs of Digestive DiseasesGeneralHandsAbdomenOrgan enlargementMassTendernessDistensionAnus & Rectum
15. Signs of Digestive DiseasesGeneralHandsAbdomenAnus & RectumHaemorrhoidsFistulaFissureRectal massesProctitis
16. Williams, Roberts, Ali, et al. for the BSG. Gut 2007
17. General statistics5% of British adults suffer from long-standing illness of the digestive tract
18. General statisticsDigestive Diseases in UK are responsible for:12% of all deaths - totalling 64,061 in 20021 in 8 of all admissions to general hospitals 1 in 4 main operations within general hospitals
19. Contrasting Patterns of Major DiseasesWorldwideMalnutritionEnteric infectionsViral hepatitis and consequencesGastric cancerUKDyspepsia / indigestion / abnormal bowelsLiver disease due to alcohol and obesityColon cancer
20. Burden of DiseasePrevalence / IncidenceMorbidityReduced quality of lifeInability to workMortalityHealth costIndividualTaxpayer
21. Mortality Rates: England & Wales
22. Liver Deaths: England & Wales
23. Age-standardised MR from CLD in Different CountriesAge Standardised Mortality from Chronic Liver Disease. Selected countries. Latest available year010203040506070New ZealandNorwayAustraliaNetherlandsIsraelSwedenCanadaJapanSwitzerlandUK: E&WUSASpainPolandFinlandFranceLatviaDenmarkPortugalCzech RepublicGermanyAustriaLithuaniaGeorgiaEstoniaRep. KoreaSlovakiaCroatiaRussiaSloveniaAzerbaijanRomaniaHungaryKyrgyzstanRate per 100,000 populationSource: WHO, EuroStatFigures standardised to European Standard Population
24. Main Causes of Chronic Liver Disease in UK4 - 6% of UK population have abnormal LFTs: - Chronic hepatitis B (0.5 – 2.0%) - Chronic hepatitis C (0.4 – 1.0%)Increasing percentages with - Alcohol related steatohepatitis - Obesity related steatohepatitis (NAFLD)Complications of cirrhosis are the major cause of death in alcoholics
25. HBV Epidemiology350 Million chronically infected1 Million deaths per year
26. Outcome of HBV Infection10%30%70%Self limiting InfectionPersistent InfectionCirrhosis +/- HCCAsymptomatic Carriage90%10%Fulminant InfectionInfection<1%
27. Reprinted from Cohen J. Science. 1999;285:26.HCV EpidemiologyPrevalence Western Europe – 1.4 %US – 2 %Japan - 2 %Romania – 4.7%Egypt – 20%
28. Self limiting infectionPersistent infection20%80%ProgressiveNon-Progressive20%80%InfectionOutcome of HCV Infection
29. DyspepsiaCommon reason for 1o / 2o care consultationsHigh NHS costsEffects on Quality of LifeRisk of complications40% of adults suffer with dyspepsia2% consult their GP£600,000,000 for endoscopies and drugs£100,000,000 for OTC medications
30. Demographics of peptic ulcer, GORD & dyspepsiaJones RH, et al. Gut 1990; Jones R. Scand J Gastroenterol 1995; Nebel OT, et al. Dig Dis 1976; Penston JG, et al. Aliment Pharmacol Ther 1996LifetimePeptic ulcerLifetimeWeekDyspepsiaLifetimeGORDData from four separate studies105060403020 0% adult population70MonthWeek DayGORD
31. Gastro-oesophageal reflux disease (GORD)
32. What is Helicobacter pylori?Gram-negative, spiral bacteriumColonises the gastric mucosaInfection persists for life unless treated
33. EpidemiologyH. pylori is found in 50% of the world’s population.Geographic distribution is closely linked to socio-economic development.http://www.helico.com/
34. Chronic gastritis85% - no long term effects 14% - peptic ulceration1% gastric adenocarcinoma or lymphomaHelicobacter Related Disease
35. Gastric ulcer & cancers
36. Duodenal ulcer
37. Bleeding ulcerPeptic ulceration affects up to 10% populationEstimated to cause up to16,500 deaths each year in USA2,000 deaths each year in UKNSAIDS & H. pylori factors
38. UK Mortality from Cancer in the GI Tract
39. Colorectal Neoplasia
40. Colorectal NeoplasiaLifetime incidencePolyps 25%Carcinoma ~6%Genetic & dietary factorsPrevention by colonoscopic screeningSurgery for cancerPrognosis excellent at early stages (5 year survival)Duke’s A 95%Duke’s B 85%Duke’s C 50%Duke’s D 15%
41. Gastrointestinal CancersLiver cancermost is metastaticprimary liver cancer (hepatocellular and cholangio carcinomas) 2000 cases paprimary liver cell cancer (HCC) higher in cirrhosiscan be detected at an early stage by ultrasound scanning50% 5 year survivalcholangiocarcinoma increased 20 fold in last 20yrs; no treatment.
42. Cholangiocarcinoma: An increasing problem?ASMR of Intrahepatic Cholangiocarcinoma in males, England and Wales, 1968-1998
43. Gastrointestinal CancersPancreatic cancer95% adenocarcinoma of pancreatic ductdifficult to diagnose earlyone of the poorest survival rates (2% at 5y)
44. Inflammatory Conditions of the IntestineUlcerative colitis & Crohn's disease (IBD)1 in 400 people in the UK8,500 new cases are diagnosed every yearGenetic effects on intestinal immune responseMorbidity & increased mortalitySepsis, drugs and surgeryCoeliac Disease1% of UK populationGenetic sensitivityGluten-free diet
45. Crohn’s diseaseTerminal IleumColon
46. Ulcerative colitis; toxic megacolon
47. Duodenal Histology in Coeliac diseaseNormalCoeliac disease
48. Biliary Diseases and ConditionsGallstonesAbout one in ten people in Britainespecially women, overweight, middle aged or overBiliary colicCholecystitisObstructive jaundiceGallbladder carcinomaAcute pancreatitis
49. Pancreatic DiseasesAcute pancreatitisMild to life-threateningBlockage of pancreatic ductBack-up of pancreatic enzymes causing severe inflammationEthanol & gallstones in 80%Chronic pancreatitisPermanent damage to pancreasAlcohol excess main causeCan greatly impair Quality of Life
50. Intestinal Diseases and ConditionsAn estimated 200 million people around the world, on any given day, suffer from diarrhoeaWater and Food-borne infectionsVirusesBacteriaParasitesClean water supply essentialEnormous global indirect costs
51. Large Bowel Diseases & ConditionsIrritable bowel syndrome (IBS) IBS is very common1 in 3 of population at one time or another1 in 10 people suffer symptoms bad enough to go to a doctorConstipation-predominantDiarrhoea-predominantBloating / pain / mixed
52. Anal Diseases & ConditionsFaecal incontinence (soiling) may affect 1 in 20 peopleAbout half the population has haemorrhoids by age 50Over half the over 70's population of the UK have diverticula of the large intestine
53. Economic Burden of GI DiseaseWellcome Trust PRISM Project 1995/6Summary of costsMortality & lost yearsAbsence from workMorbidityNHS prescription costs
54. Population based mortality rates for major disease groupings, inEngland and Wales, 2000: people of all ages. Source: ONS, 2001.
55. Mortality from Digestive Diseases
56. Economic Burden of GI Disease in UK(BSG PRISM study – Wellcome Trust 1995/6; updated to 2004)Loss of productive work dying early £3.23 billionlong-term absence £1.05 billionshort-term absence £2.90 billion Total = £7.18 billionNHS costs in-patients £1.40 billionprimary care £0.14 billionDrugs £0.80 billion Total = £2.34 billion+ out-patients + community services Total > £10 billion
57. Cost of NHS PrescriptionsClasses of drug (BNF)AntacidsAntispasmodicsUlcer-healingChronic diarrhoeal agentsLaxativesHaemorrhoid treatmentStoma careIntestinal secretion drugsIn 2002, 60 million prescriptions for GI drugsTotal cost to NHS for drug alone was £802 million£596 million for ulcer-healing drugs£51 million for laxatives
58. Diseases of the Digestive TractDiverse group of conditionsMajor impact on healthSignificant economic burdenSignificant impact on Quality of Life