Pemicu 1 Blok GIT

Theffany
405120198
Fakultas Kedokteran
Universitas Tarumanagara
 LO
1. Anatomi, histologi, biokimia, fisiologis dari upper
GI tract ( mulut- esophagus)
2. Dysphagia
3. Vomit
 LO 1

Anatomy
 Mouth
Reffered as oral / buccal activity
Formed by the cheeks, hard and soft palates and
tongue
The cheeks from the lateral walls of the oral cavity,
covered extenally by skin and internally by a mucous
membran, consist of non keratinized stratified
squamous epithelium
 Lips or Labia
Fleshy folds swallowing the opening of the mouth
Contain the orbicularis oris muscle and covered
externally by skin and internally by a mucosa
membran
The inner surface of each lips is attached to gum by a
midline fold of mucosa membran called the labial
frenulum
 Oral vestibule
Space bounded externally by the cheeks and lips and
internally by gum and teeth
 Palate
A septum / wall that separates oral cavity from the nasal
cavity / and forms the root of the mouth
Hard palate/ durum  anterior portion, formed by maxillae
and palatine bones and covered by mucous membran
Soft palate / mole  posterior portion of the root of the
mouth, is an arch shapped muscular portion between
oropharynx and nasopharynx that is lined with mucous
membran
Hanging from free border of the soft palate is called uvula,
during swallowing, the soft palate and uvula are drawn
superiorly, closing the nasopharinx and preventing
swallowing foods and liquid from entering nasal cavity.
 Salivary glands
Release a secretion called saliva into the oral cavity.
Saliva is secreted to keep the mucous membranes of
the mouth and pharynx moist and cleanse the mouth
and teeth
3 pairs of major salivary glands
1. Parotid  is located inferior and anterior to the cars,
between the skin and masseter muscle
2. Submandibular glands  found in the floor of mouth
3. Sublingual glands  beneath the tongue and superior
to the submandibular glands
 Tongue
Accessory digestive organ composed of skeletal muscle
covered with mucous membranes. It form the floor of the
oral cavity
Divided into symetrical lateral halves by a median septum
Consult of extrinsic and intrinsic muscle
 Ektrinsic muscle  hyglossus, genioglossus, styloglossus
 Intrinsic muscle  longitudinal superior and inferior,
tranversus linguae, vertical linguae
• Dorsum and lateral surface of tongue are covered with
papillae that confirm taste buds, reseptor s for gustation
(taste).
 Teeth
Located in sockets od the alveolar processes of the
mandibule and maxillae
The alveolar processes are covered by the gingivae or
gum, which extend slightly into each socket that lined
by periodontal ligament which consist of dense
fibrouse connective tissue.
 dentin
Consist of calcified connective tissue that give tooth its
basic shape and rigidity
Harder than bone < content calcium salts>
Covered by enamel that consist of calcium , phosphate
and calcium carbonate
Dentin of the root is covered by cementum, which
attaches the roor to the periodontal ligament
 Pulp
Connective tissue containing blood vessel, nerves and
lympatic vessel
Blood vessel bring nourishment
Lymphatic vessel offer protection
Nerves provides sensation
 Dentitions
Desiduous teeth/ primary / milk teeth
Begin to erupt at about 6 month of age
Approximately two teeth appear each month until all 20
are present
Permanent/ secondary teeth
Contain 32 teeth that erupt between age 6 and adulhood
 Pharynx
Is a funnel shaped tube that extend from the internal
nares of esophagus posteriorly and to the larynx
anteriorly
Composed skeletal muscle and line by mucous
membran
Divided into 3 parts :
 nasopharynx , oropharynx, laryngopharynx
Swallowed food passed from the mouth into the
oropharynx and laryngopharynx, muscular contraction
of these areas help prople food into the esophagus and
then into the stomach
 Esophagus
Collapsible muscular tube, about 25cm long that lies
posterior to the trachea
Begins at the inferior end of the laryngopharynx and
the enters the mediastinum anterior to the vertebral
column
Histology
 Layers of GI
Mucosa
Composed of :
a layer of epithelium in direct contact with content of the
GI.
A layer of connective tissue called lamina propria.
A thin layer of smooth muscle
 Layers of GI
Epithelium in mouth, pharynx, esophagus is mainly non
keratinized stratified squamous epithelium that serves a
protective function.
Lamina propria is alveolar connective tissue containing
many blood vessel and lymphatic vessel  the routes by
which nutrients absorbed into the GI tract.
 Also contain majority cells of the mucosa associated lymphatic
tissue (MACT) that contain immune system cells.
Muscularis mucose
A thin layer of the smooth mucle fibre
Submucosa
Consist of alveolar connective tissue that binds the mucosa to
the muscularis.
Contains many blood and lymphatic vessel, glands and
lymphatic tissue
Muscularis
the muscularis of the mouth, pharynx and superior and
middle of esophagus contain skeletal muscle produce
voluntary swallowing
Found in two sheet : an inner sheet of circular fibre and an
outer sheet of longitudinal fibers.
Between the layers of muscularis called myenteric plexus.
Serosa
Serous membran composed of alveolar connective tissue
and simple squamous epithelium.
Esophagus lacks a serosa, anly a single layers of alveolar
connective tissue called adventitia.
 Mouth and tongue
Mucosa consist of stratified squamous epithelium that
considerable protection against abrasion from food
particles that are chewed, mixed with secretory and
swallowed.
The submucosa contains alveolar connective tissue,
blood vessel and mucosa gland
The muscularis of
the superior third of esophagus id skeletal muscle
The intermediate third is skeletal and smooth muscle
The inferior third is smooth muscle
The superficial layer of esophagus is known as
adventitia
Labium Oris
1. Pars cutanea / outer layer
a. Stratified keratinizing
squamous cell epithelium
b. Hair follicle with sebaceous
and sweat glands
c. Orbicularis oris muscle
2. Pars Intermedia/Vermillion
border : A
3. Pars oral mucosa : B
a. Stratified nonkeratinizing
squamous cell epithelium
b. Tunica propria
 Labialis glands
c. Orbicularis oris muscle
d. Labialis artery
e. Small chorium
Labium Oris
There are 3 forms of
papillae:
Circumvalata papillae:
 Circumvalata papillae:
 Secondary papillae
 Taste bud
 Ebneri glands
Filiform papillae (A)
Fungiform papillae (B)
Labium Oris
 Esophagus
Mucosa consist of non keratinized stratified squamous
epithelium, lamina propria and muscularis mucosa.
Esophagus
A. Tunica mucosae
1. Stratified
nonkeratinizing
squamous cell
epithelium
2. T. propria
3. T. muscularis mucosae
B. Tunica submucosae
4. Oesephagus glands
5. Excretory duct
C. Tunica muscularis
6. T. Musc. Circular
7. T.Musc. Longitudinal
D. Tunica adventitia
Physiology
The digestive system performs 4 basic digestive processes :
1. Motility
Muscular contractions that mix and more forward the
contents within the track
2. Secretion
digestive system produces both exocrine & endocrine
secretions, each digestive secretions consist of water,
electrolytes, & spesific organic constituents such as enzyme,
bile salts or mucus
3. Digestion
Chemically break down the structurally complex food
stuffs
(carbohydrate, protein, fats) of diet into smaller,
absorbable units
4. Absorption
Small absorbable units that result from digestion, along with
water, vitamins, and electrolytes, are transferred from the
digestive tract lumen into the blood/ lymph
 MOUTH
Entry to digestive track is trough the mouth/ oral
cavity
The opening is formed by muscular lips
The palate presence allows breathing & chewing or
sucking to take place simulttaneously
The tounge guides food within the mouth during
chewing & swallowing and also plays on important
role in speech and the location of taste buds
Teeth mechanically break down food stuffs
1st step : mastication/ chewing
The motility of mouth that involves slicing, tearing,
grinding, and mixing of ingested food by the teeth
The function of chewing:
1. To grind & break food into smaller places to
facilitate swallowing and to increase the food surface
are on which salivary enzyme can act
2. To mix food with saliva
3. To stimulate the taste buds
Gives rice to pleasurable subjective sensation of
taste
Reflexly increases salivary, gastric, pancreatic, bile
secretion to prepare for the arrival or food
 Saliva
Secretion associated with the mouth, is produced largely
by 3 mayor pairs of salivary glands

99,5% H2O ; 0,5% electrolytes and protein

Contribute to the functions or saliva, which are :

1. Begins digestion of dietary starches through action of
enzyme salivary amylase
2. Facilitates swallowing by moistening food particles and
providing lubrication through the presence of mucus
3. Exerts some antibacterial action by lysozyme : enzyme
that lyse/ destroys certain bacteria by break down the cell
wallls by binding glycoprotein : that binds IgA antibodies,
by lactoferin that binds to iron needed for bacterial
multiplication, by rinsing away material that be food
source for bacteria
 4. Serves as a solvent that stimulate the taste buds
5. Facilitating movement of lips and tounge
6. Oral hygiene
7. Rich in bicarbonate buffers : neutralize acids

 On average, about 1-2 L of saliva are secreted per

day
 In the absense of food-related stimuli, low level
parasympatic stimulation in production of basal
salivary secretion that keeping the mouth mast at all
timer
 Control of Salivary Secretion
Thinking of
Pressure receptors Salivary food
Cerebral
& chemoreseptors center in
cortex
in mouth medula
Seeing food

Smelling
Autonomic food
Conditioned
Simple reflex nerves reflex

Salivary
glands • Parotid gland
• Submandibular gland
• Sublingual gland
Salivary
secretion
 PHARYNX AND ESOPHAGUS
Pharynx
Acts as a passageway for both the digestive & rspiratory
system
The side wall of oropharynx are tonsils : lymphoid tissues
that past of body’s deffense
Motility associated with the pharynx and esophagus is
swallowing
Swallowing sequentially programmed all or none reflex
Initiated when a bolus/ liquid food is voluntarily force by the
tounge to be mouth and into the pharynx
 OROPHARYNGEAL AND ESOPHAGEAL STAGE OF
SWALLOWING
1. Swallowing is initiated voluntarily at start of
swallow, tounge presses bolus against hard palate
2. Tongue propels bolus to pharynx
3. Swallowing center inhibits respiratory center in the
brain stem
4. Elevation of uvula prevents food from entering nasal
passageways
5. Position of tongue prevent food reentering mouth
6. Tight alignment of vocal cards prevents food from
entering trachea
7. Epiglottis folds over closed glottis
8. Contraction of pharyngeal muscles pushes bolus through
opened pharyngoesophageal sphincter into esophagus
9. Pharyngoseophageal sphincter closes, oropharingeal
structures return to resting position and breathing
resumes
10. Peristalsis propels bolus down length of esophagus
11. Gastroesophageal sphincter relaxes as peristalsis pushes
bolus into stomach. Swallow is complete sphincter again
contracts
Sherwood L. Introduction to human physiology. 8th
ed. United States: Brooks/Cole-Cengage Learning;
2013.
Sherwood L. Introduction to human physiology. 8th
ed. United States: Brooks/Cole-Cengage Learning;
2013.
Sherwood L. Introduction to human physiology. 8th
ed. United States: Brooks/Cole-Cengage Learning;
2013.
ESOPHAGUS
Straight muscular tube that exterds between the
pharynx and the stomach
Guarded at both ends by sphincter
Esophageal secretion is entirely mucus : lubricates
passage of food, protect esophagus from damage by
acid and enzymes in gastric juice is gastric reflux
occur
Entire transit time in pharynx and esophagus are mere
6-10s
Biochemistry
Hormones and Enzymes
LO 2. Dysphagia
 Dysphagia
Condition which disruption of swallowing processes
Can result in aspiration, pneumonia, malnutrition,
dehydration, weight loss and airway obstruction
 Pediatric patients
Succesful oral feeding and growth in infant and
children depent on functional deglutition, broad range
of neurodevelopmental skills involve sensory system,
cognition, communication, gross and fine motor
behaviour
Premature and neurologic impairment are common
cause dysphagia in young patients
 Classification
Oropharyngeal dysphagia
Oropharyngeal phase of swallowing is a complex
requiring elevation of the tongue, closure of the airway
and pharyngeal peristaltis.
Characterized by an immediate sense of the bolus
catching in the neck, couching or chocking during meals
Esophageal dysphagia
Cause by mechanical lession obstruction the dysphagia
or by motility disorder
Patients with mechanical obstruction dysphagia, primary
for solids
Patiens with motility disorder have dysphagia for both
solids and liquids
 Etiology
Central nervous system disorder (CNS)  brain
tumors, stroke, cerebral palsy, guillain-barre syndrome,
etc
Muscular disorder  muscular dystrophies,
polymielitis, dermatomyositis
Sensory neurophatic  affecting laryngeal nerves
 Endocrine disorders  cushing syndrome, hypothyroidism
 Pharmacology cause  causing a decrease in cognition/
rise to drug induced myopathies
 Mucosal injury caused by drugs  potassium chloride
tablets, NSAID, antibiotic such as : tetracycline,
clindamycin
Surgical causes  laryngectomy, pharyngectomy
Motility disorders  achalasia , scleroderma
Esophagitis  GERD, candidiasis
Stuctural disorder esophageal strictures,
tracheoesophageal fistula
 Sign and symptoms
Oral/ pharyngeal sysphagia include :
1. coughing/ choking with swallowing
2. difficulty initiating swallowing
3. recurrent pneumonia
4. weight loss
5. change in voice / speech
6. food sticking in the throat
Esophageal dysphagia including :
1. change in dietary habits
2. recurrent pneumonia
3. symptoms of GERD ( heartburn, sour
regurgitation)
 ROME III
Diagnostic criteria of functional dysphagia
1. Sense of solid and/or liquid food sticking, lodging, or
passing abnormally through the esophagus
2. Absence of evidence that gastroesophageal reflux is the
cause of the symptom
3. Absence of evidence that histopathology-based
esophageal motility disorder

Criteria fulfilled for the last 3 months with symptom onset

on least 6 months prior to diagnosis
Must include all criteria
 Physical examination
Examination of the neck, mouth, oropharynx, larynx
Oral-motor and laryngeal mechanisms ( lips, jaw,
closure, oral sensitivity, chewing & mastication,
tongue motility & strength)
Check level of alertness and cognitive status
Inspect the oral cavity and pharynx for mucosal
integrity and dentition
Observe act of swallowing at a mininum
 Work up
Transnasal esophagoscopy
Cervical auscultation
Blood test
Imaging studies
Endoscopic examination
Esophageal ph monitoring
Scintigraphy (evaluate swallowing disorder )
 Differential Diagnoses
Achalasia
Myasthenia gravis
Pediatric poliomyelitis
Scleroderma
 Treatment
Goals : maintain adequate nutritional intake for the
patient and to make maximize airway protection
Rehabilitation include : dietary modification &
training in swallowing technique

Pharmacologic treatment
Botulinum toxin type, diltiazem, glucakon, cystein- depleting
therapy with cysteamine, nitrates <achalagia>
 Dietary modification
Viscosity and texture:
The dysphagia diet can be classified according to
viscosity
• Level I : pudding, crushed potato, ground meat
• Level II : orange juice, cream soup
• Level III : tomato juice, fluid type yogurt
• Level IV : water and orang juice
 Hydration
Fluid intake restricted in most patients with
dysphagia : risk of dehydration  depress imune
system susceptible to infections pneumonia

IV fluid boluses given maybe necessary if hydration

can’t be mantained
 Exercise
LIPS : lips exercise can be facilitated the patient
ability to prevent food/ liquid from leaking out of
the oral cavity
HEAD LIFT : increase anterior movement of the
hyolaryngeal complex and opening of the upper
esophageal sphincter
JAW : jaw exercise to facilitate the rotatory
movements of mastication
LO 3. VOMITING
Definition
 Abnormal emptying of stomach and upper part of
intestine via esophagus through mouth.
 This is not the same as regurgitation, which refers
to emitting already swallowed food, and must be
distinguished correctly.
 Vomiting is often related to or preceded by nausea,
but both nausea-without-vomiting and vomiting-
without-nausea are possible.
 Any nausea or vomiting symptom needs prompt
professional medical investigation.
Etiology
Irritation in GIT
Mechanical stimulation of pharynx
Pregnancy
 Alcohol
Stimulation of labyrinth of ear eg sea
sickeness,mountain sickeness
Acute GI infection
Metabolic disorders
Increase Intracranial Pressure
Mechanism
Receptors are stimulated which contribute impulses to the vomiting center in the brain

Sensory impulse stream from receptors reach the vomiting center and initiate a number of
motor responses.

The diaphragm and the skeletal muscles of the abdominal wall contract

Increase the intra-abdominal pressure

The cardiac sphincter relaxes and soft palate rise to close off the nasal passage

The stomach (or intestinal) contents are then forced upward through the esophagus,
pharynx and out the mouth

Emesis or Vomiting
Mechanism
Mechanism
Predisposition factor
Emesis is early manifestation of some disease,
therefore closer identification its so important, there
are :
Age and sex
Diet
Nutrient status of child
 Vomit contains
There is child disease which attack
Medical examination
Analysis of urine and blood
Abdomen X-Ray with or without contrast
USG
Endoscopy with biopsy
Psychiatry check up
Home Care of Nausea & Vomiting
Monitor for dehydration 
Signs of mild dehydration include:
 A slightly dry mouth
 Thirst
 Children who are mildly dehydrated do not need immediate medical
attention but should be monitored for signs of worsening
dehydration.
Signs of moderate or severe dehydration include:
 Decreased urination (not going to the bathroom or no wet diaper in
6 hours)
 A lack of tears when crying
 A dry mouth
 Sunken eyes
Home Care of Nausea & Vomiting
Dietary recommendations
Infant
 Continue the breastfeed
 Oral rehydration therapy
Older infants and children
 Monitor for signs of dehydration. Other fluids, including water,
diluted juice, or soda can be given in small quantities.
 Apple, pear, and cherry juice, and other beverages with high
sugar content, should be avoided.
 Recommended foods include a combination of complex
carbohydrates, lean meats, yogurt, fruits, and vegetables. High fat
foods are more difficult to digest, and should be avoided.
Home Care of Nausea & Vomiting
Oral rehydration therapy
 Liquid solution that contains glucose (a sugar) and electrolytes
(sodium, potassium, chloride), which are lost with vomiting and
diarrhea.
Antiemetics
When to Seek Help?
You should call your doctor or nurse immediately if your child
has any of the following:
Bile (green) or blood-tinged (red or brown) vomit
Any episode of vomiting in a newborn, or vomiting that continues
for more than 24 hours in an infant or child
If an infant refuses to eat or drink anything for more than a few
hours
Moderate to severe dehydration (dry mouth, no tears when crying,
not urinating or having a wet diaper in six hours)
Abdominal pain that is severe, even if it comes and goes
Fever higher than 102ºF (39ºC) once or fever higher than 101ºF
(38.4ºC) for more than three days
Behavior changes, including lethargy or decreased responsiveness
Complication
Loosing fluid and electrolit
Aspiration of gaster contents
Malnutrition and failed to growing up
Sindrom Mallory-Weiss (rupture at epitel of
gastroesopageal junction because of repeated vomit )
Sindrom Boerhave (rupture esofagus)
Esofagitis peptikum
GER – GERD
Classifications
Physiologic (or functional) gastroesophageal reflux:
No underlying predisposing factors or conditions
Growth and development are normal, and pharmacologic
treatment is typically not necessary
Pathologic gastroesophageal reflux or
gastroesophageal reflux disease (GERD):
Patients frequently experience complications noted
above, requiring careful evaluation and treatment
Secondary gastroesophageal reflux :
Underlying condition may predispose
Ex. Asthma and gastric outlet obstruction
Sign & Symptoms (infants)
Typical or atypical crying and/or irritability
Apnea and/or bradycardia
Poor appetite
Apparent life-threatening event (ALTE)
Vomiting
Wheezing
Abdominal and/or chest pain
Stridor
Failure to thrive
Recurrent pneumonitis
Sore throat
Chronic cough
Waterbrash
Physical
In toddlers and older children, may lead to significant
dental problems caused by acid effects on tooth
enamel
Esophagitis
Causes
Anatomic Factors
The angle of His (made by the esophagus and the axis of
the stomach) is obtuse in newborns but decreases as
infants develop. This ensures a more effective barrier
against gastroesophageal reflux.
The presence of a hiatal hernia may displace the lower
esophageal sphincter (LES) into the thoracic cavity
Resistance to gastric outflow raises intragastric pressure
and leads to reflux and vomiting.
Causes
Others :
Medications (diazepam etc)
Smoking
Alcohol
Food and poor dietary habbit, allergies
Motility disorder
tLESR
Obesity
Supine position
Decreased gastric emptying and reduced acid clearance
from the esophagus: These can cause abnormal reflux
Imaging Studies
Upper GI Imaging Series
Not spesific
Evaluation of gastric emptying phase
Gastric Scintiscan
using milk or formula that contains a small amount of technetium
sulfur colloid, can assess gastric emptying and can reveal reflux
(although not the degree or severity)
Esophagography
Strictures can be demonstrated by esophagography.
Chronic esophageal mucosal injury secondary to gastroesophageal
reflux involves a mucosal/submucosal inflammatory cell infiltrate as
well as basal cell hyperplasia. In severe cases, this may appear as a
ragged mucosal outline on radiography
Medications
Changes in diet and lifestyle :
Appropriate weight management of overweight or obese
children is important
Avoid the seated or the supine position shortly after
meals. In addition, sleeping in the prone position has
been demonstrated to decrease the frequency of
gastroesophageal reflux
Placing blocks under the head of the bed or placing a
foam wedge under the patient's mattress can accomplish
this.
Treatment & Prognosis
GE reflux resolves spontaneously in 85% of affected
infants by 12 months of age, coincident with
assumption of erect posture and initiation of solid
feedings.
Until then, regurgitation volume may be reduced by
offering small feedings at frequent intervals and
by thickening feedings with rice cereal (2–3 tsp/oz of
formula).
Prethickened "anti-reflux" formulas are available.
Treatment & Prognosis
Histamine-2 (H2)–receptor antagonists (ranitidine, 5
mg/kg/d in two doses) or
proton pump inhibitors (omeprazole, 0.5–1.0 mg/kg/d
in one dose) do not reduce the frequency of reflux but
may reduce pain behavior.
Prokinetic agents such as metoclopramide hasten
gastric emptying and improve esophageal motor
function, but studies have not shown efficacy in
controlling symptoms.
Treatment & Prognosis
A 2-week trial of protein hydrolysate formula
(hypoallergenic) sometimes controls emesis and pain
behavior in infants with protein sensitivity.
Special formulas and acid suppression agents are
costly and should be discontinued if there is no
improvement of symptoms in 1–2 weeks.
Treatment & Prognosis
Antireflux surgery (fundoplication) is indicated when GERD is
unresponsive to medications, thus leading to severe symptoms
that include
(1) persistent vomiting with failure to thrive,
(2) esophagitis or esophageal stricture,
(3) life-threatening apneic spells, or
 (4) chronic pulmonary disease unresponsive to 2–3 months of
maximal medical therapy.
Fundoplication also may be considered in patients whose
response to medication is likely to be poor—those with large
hiatal hernia, neurologic handicap, previous TE fistula surgery,
or severe esophagitis.