Theme 4:
Digestive Tract
Summary
,Content
Week 12: Difficulty swallowing ............................................................................................................... 6
Anatomy .............................................................................................................................................. 6
The cranial nerves ........................................................................................................................... 6
The neck .......................................................................................................................................... 7
The nasal cavity ............................................................................................................................. 11
The oral cavity ............................................................................................................................... 11
The pharynx ................................................................................................................................... 13
The larynx ...................................................................................................................................... 16
Physiology.......................................................................................................................................... 18
Swallowing..................................................................................................................................... 18
Phonation ...................................................................................................................................... 19
Common disorders of the neck ......................................................................................................... 22
Pharynx .......................................................................................................................................... 22
Larynx ............................................................................................................................................ 23
Oesophagus ................................................................................................................................... 25
Malignancy of the upper digestive tract ........................................................................................... 28
Radiotherapy in head-and-neck cancer ............................................................................................ 29
Radiation ....................................................................................................................................... 29
Treatment ...................................................................................................................................... 29
Toxicity .......................................................................................................................................... 29
Prevention ..................................................................................................................................... 29
Nutrition ............................................................................................................................................ 31
Cachexia......................................................................................................................................... 32
Sarcopenia ..................................................................................................................................... 32
Sarcopenic obesity......................................................................................................................... 33
Nutritional screening tools ............................................................................................................ 34
Nutritional assessment .................................................................................................................. 35
Treatment ...................................................................................................................................... 35
Week 13: Heartburn .............................................................................................................................. 36
Gastroesophageal reflux ................................................................................................................... 36
Stomach pain ................................................................................................................................. 36
Disorders of the oesophagus............................................................................................................. 37
GORD ............................................................................................................................................. 38
Hiatus hernia ................................................................................................................................. 38
Barrett oesophagus ....................................................................................................................... 38
2
, Candida oesophagitis .................................................................................................................... 40
Achalasia ........................................................................................................................................ 40
Haemorrhage................................................................................................................................. 40
Oesophageal tumours ................................................................................................................... 41
Disorders of the stomach .................................................................................................................. 42
Dyspepsia....................................................................................................................................... 42
Helicobacter pylori ........................................................................................................................ 42
Bleeding in the stomach ................................................................................................................ 44
Gastric tumours ............................................................................................................................. 44
Disorders of the pancreas ................................................................................................................. 46
Pancreatitis .................................................................................................................................... 46
Disorders of the small intestine ........................................................................................................ 47
Coeliac disease .............................................................................................................................. 47
Irritatable bowel syndrome ........................................................................................................... 47
Short intestine disease .................................................................................................................. 48
Embryology........................................................................................................................................ 49
The foregut .................................................................................................................................... 52
Anatomy ............................................................................................................................................ 56
Peritoneal cavity ............................................................................................................................ 56
The stomach .................................................................................................................................. 57
The duodenum .............................................................................................................................. 57
Pancreas ........................................................................................................................................ 58
Spleen ............................................................................................................................................ 58
Arterial supply to the abdominal viscera ...................................................................................... 60
Venous drainage ............................................................................................................................ 62
Veins of the abdomen ................................................................................................................... 63
Hepatic portal system of veins ...................................................................................................... 64
Pharmacology .................................................................................................................................... 65
The stomach wall........................................................................................................................... 65
Cytochrome P450 enzymes (CYP450) ........................................................................................... 65
Drugs to treat gastric problems..................................................................................................... 66
Gastric protective therapy............................................................................................................. 69
Week 14: Jaundice................................................................................................................................. 70
Anatomy ............................................................................................................................................ 70
Histology ............................................................................................................................................ 71
The liver ......................................................................................................................................... 71
3
, Vasculature of the liver ................................................................................................................. 71
Histological structure of the liver .................................................................................................. 73
The hepatocyte and vascular sinus ............................................................................................... 75
Bile ducts ....................................................................................................................................... 76
Physiology.......................................................................................................................................... 78
The liver ......................................................................................................................................... 78
The gall bladder ............................................................................................................................. 81
Bilirubin ......................................................................................................................................... 82
Diagnostics in liver problems ............................................................................................................ 84
Physical examination ..................................................................................................................... 84
Imaging for the hepatobiliary and pancreatic region.................................................................... 85
Disorders of the liver and bile ducts.................................................................................................. 86
Hepatitis ........................................................................................................................................ 86
Cirrhosis ......................................................................................................................................... 87
Liver failure .................................................................................................................................... 89
Alcoholic liver disease and non-alcoholic steatohepatitis (NASH) ................................................ 90
Cholecystolithiasis and choledocholithiasis .................................................................................. 91
Cholangitis ..................................................................................................................................... 92
Primary sclerosing cholangitis ....................................................................................................... 93
Primary biliary cirrhosis ................................................................................................................. 94
Carcinoma of the pancreas............................................................................................................ 95
Week 14: Blood in the stool .................................................................................................................. 97
Architecture and function ................................................................................................................. 97
Layers of the digestive tract .......................................................................................................... 97
Digestive enzymes and juices ............................................................................................................ 98
Absorption of nutrients: in small intestine by enterocytes............................................................... 99
Regulation of the gastrointestinal tract .......................................................................................... 101
Digestive hormones ..................................................................................................................... 101
Digestive organs and their function ................................................................................................ 102
Small intestine ............................................................................................................................. 102
Large intestine ............................................................................................................................. 103
Disorders of the gut ......................................................................................................................... 104
Inflammatory bowel disease (IBD) .............................................................................................. 104
Haemorrhoids .............................................................................................................................. 104
Perianal abcess ............................................................................................................................ 105
Perianal fistula ............................................................................................................................. 106
4
, Anal fissure .................................................................................................................................. 106
Sinus pilonidalis ........................................................................................................................... 106
Anal carcinoma ............................................................................................................................ 107
Colorectal polyps ......................................................................................................................... 108
Colorectal adenocarcinoma ........................................................................................................ 109
Diverticulosis vs diverticulitis ...................................................................................................... 112
Diarrhoea ..................................................................................................................................... 112
Stoma............................................................................................................................................... 114
Complications .............................................................................................................................. 115
Secondary prevention ..................................................................................................................... 116
Test properties ............................................................................................................................ 116
Advantages and disadvantages of screening .............................................................................. 117
Criteria for introducing a screening program .............................................................................. 118
Screening programs in the Netherlands...................................................................................... 118
5
,Week 12: Difficulty swallowing
Anatomy
The cranial nerves
Number Nerve
I Olfactory
II Optic
III Oculomotor
IV Trochlear
V Trigeminal
VI Abducens
VII Facial
VIII Vestibulocochlear
IX Glossopharyngeal
X Vagus
XI Accessory
XII Hypoglossal
6
,The neck
Anterior cervical region
Sternocleidomastoid region
Lateral cervical region
Posterior cervical region
Muscles of the neck
Suprahyoid muscles: raise hyoid bone towards a stabilised mandible during swallowing
Infrahyoid muscles: depress the hyoid bone and larynx during swallowing and vocalisation
➔ Extrinsic muscles of the larynx →
7
, Nerves
8
Digestive Tract
Summary
,Content
Week 12: Difficulty swallowing ............................................................................................................... 6
Anatomy .............................................................................................................................................. 6
The cranial nerves ........................................................................................................................... 6
The neck .......................................................................................................................................... 7
The nasal cavity ............................................................................................................................. 11
The oral cavity ............................................................................................................................... 11
The pharynx ................................................................................................................................... 13
The larynx ...................................................................................................................................... 16
Physiology.......................................................................................................................................... 18
Swallowing..................................................................................................................................... 18
Phonation ...................................................................................................................................... 19
Common disorders of the neck ......................................................................................................... 22
Pharynx .......................................................................................................................................... 22
Larynx ............................................................................................................................................ 23
Oesophagus ................................................................................................................................... 25
Malignancy of the upper digestive tract ........................................................................................... 28
Radiotherapy in head-and-neck cancer ............................................................................................ 29
Radiation ....................................................................................................................................... 29
Treatment ...................................................................................................................................... 29
Toxicity .......................................................................................................................................... 29
Prevention ..................................................................................................................................... 29
Nutrition ............................................................................................................................................ 31
Cachexia......................................................................................................................................... 32
Sarcopenia ..................................................................................................................................... 32
Sarcopenic obesity......................................................................................................................... 33
Nutritional screening tools ............................................................................................................ 34
Nutritional assessment .................................................................................................................. 35
Treatment ...................................................................................................................................... 35
Week 13: Heartburn .............................................................................................................................. 36
Gastroesophageal reflux ................................................................................................................... 36
Stomach pain ................................................................................................................................. 36
Disorders of the oesophagus............................................................................................................. 37
GORD ............................................................................................................................................. 38
Hiatus hernia ................................................................................................................................. 38
Barrett oesophagus ....................................................................................................................... 38
2
, Candida oesophagitis .................................................................................................................... 40
Achalasia ........................................................................................................................................ 40
Haemorrhage................................................................................................................................. 40
Oesophageal tumours ................................................................................................................... 41
Disorders of the stomach .................................................................................................................. 42
Dyspepsia....................................................................................................................................... 42
Helicobacter pylori ........................................................................................................................ 42
Bleeding in the stomach ................................................................................................................ 44
Gastric tumours ............................................................................................................................. 44
Disorders of the pancreas ................................................................................................................. 46
Pancreatitis .................................................................................................................................... 46
Disorders of the small intestine ........................................................................................................ 47
Coeliac disease .............................................................................................................................. 47
Irritatable bowel syndrome ........................................................................................................... 47
Short intestine disease .................................................................................................................. 48
Embryology........................................................................................................................................ 49
The foregut .................................................................................................................................... 52
Anatomy ............................................................................................................................................ 56
Peritoneal cavity ............................................................................................................................ 56
The stomach .................................................................................................................................. 57
The duodenum .............................................................................................................................. 57
Pancreas ........................................................................................................................................ 58
Spleen ............................................................................................................................................ 58
Arterial supply to the abdominal viscera ...................................................................................... 60
Venous drainage ............................................................................................................................ 62
Veins of the abdomen ................................................................................................................... 63
Hepatic portal system of veins ...................................................................................................... 64
Pharmacology .................................................................................................................................... 65
The stomach wall........................................................................................................................... 65
Cytochrome P450 enzymes (CYP450) ........................................................................................... 65
Drugs to treat gastric problems..................................................................................................... 66
Gastric protective therapy............................................................................................................. 69
Week 14: Jaundice................................................................................................................................. 70
Anatomy ............................................................................................................................................ 70
Histology ............................................................................................................................................ 71
The liver ......................................................................................................................................... 71
3
, Vasculature of the liver ................................................................................................................. 71
Histological structure of the liver .................................................................................................. 73
The hepatocyte and vascular sinus ............................................................................................... 75
Bile ducts ....................................................................................................................................... 76
Physiology.......................................................................................................................................... 78
The liver ......................................................................................................................................... 78
The gall bladder ............................................................................................................................. 81
Bilirubin ......................................................................................................................................... 82
Diagnostics in liver problems ............................................................................................................ 84
Physical examination ..................................................................................................................... 84
Imaging for the hepatobiliary and pancreatic region.................................................................... 85
Disorders of the liver and bile ducts.................................................................................................. 86
Hepatitis ........................................................................................................................................ 86
Cirrhosis ......................................................................................................................................... 87
Liver failure .................................................................................................................................... 89
Alcoholic liver disease and non-alcoholic steatohepatitis (NASH) ................................................ 90
Cholecystolithiasis and choledocholithiasis .................................................................................. 91
Cholangitis ..................................................................................................................................... 92
Primary sclerosing cholangitis ....................................................................................................... 93
Primary biliary cirrhosis ................................................................................................................. 94
Carcinoma of the pancreas............................................................................................................ 95
Week 14: Blood in the stool .................................................................................................................. 97
Architecture and function ................................................................................................................. 97
Layers of the digestive tract .......................................................................................................... 97
Digestive enzymes and juices ............................................................................................................ 98
Absorption of nutrients: in small intestine by enterocytes............................................................... 99
Regulation of the gastrointestinal tract .......................................................................................... 101
Digestive hormones ..................................................................................................................... 101
Digestive organs and their function ................................................................................................ 102
Small intestine ............................................................................................................................. 102
Large intestine ............................................................................................................................. 103
Disorders of the gut ......................................................................................................................... 104
Inflammatory bowel disease (IBD) .............................................................................................. 104
Haemorrhoids .............................................................................................................................. 104
Perianal abcess ............................................................................................................................ 105
Perianal fistula ............................................................................................................................. 106
4
, Anal fissure .................................................................................................................................. 106
Sinus pilonidalis ........................................................................................................................... 106
Anal carcinoma ............................................................................................................................ 107
Colorectal polyps ......................................................................................................................... 108
Colorectal adenocarcinoma ........................................................................................................ 109
Diverticulosis vs diverticulitis ...................................................................................................... 112
Diarrhoea ..................................................................................................................................... 112
Stoma............................................................................................................................................... 114
Complications .............................................................................................................................. 115
Secondary prevention ..................................................................................................................... 116
Test properties ............................................................................................................................ 116
Advantages and disadvantages of screening .............................................................................. 117
Criteria for introducing a screening program .............................................................................. 118
Screening programs in the Netherlands...................................................................................... 118
5
,Week 12: Difficulty swallowing
Anatomy
The cranial nerves
Number Nerve
I Olfactory
II Optic
III Oculomotor
IV Trochlear
V Trigeminal
VI Abducens
VII Facial
VIII Vestibulocochlear
IX Glossopharyngeal
X Vagus
XI Accessory
XII Hypoglossal
6
,The neck
Anterior cervical region
Sternocleidomastoid region
Lateral cervical region
Posterior cervical region
Muscles of the neck
Suprahyoid muscles: raise hyoid bone towards a stabilised mandible during swallowing
Infrahyoid muscles: depress the hyoid bone and larynx during swallowing and vocalisation
➔ Extrinsic muscles of the larynx →
7
, Nerves
8
