FARAH SAAD, A 21

Y/O COMPLAINT OF
DIARRHOEA FOR THE
LAST 4-5 MONTHS

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01
Anatomy of lower
GIT
shukri
Anatomy of lower GIT
Lower GIT

Large intestine

1) Large Intestine

Consist of 5:

i) Caecum
ii) Appendix
iii) Colon: Ascending, Transverse, Descending and Sigmoid colon
iv) Rectum
v) Anal Canal
Anatomy of lower GIT
1) Large Intestine

i) Caecum

Location -Intraperitoneal in right iliac fossa (between ileocecal junction

and ascending colon)

Blood supply -anterior & posterior caecal branches of ileocolic artery

(superior messenteric artery)

Innervation -superior mesenteric plexus

Lymphatic drainage -ileocolic lymph nodes

Anatomy of lower GIT
1) Large Intestine

ii) Appendix

Location -Intraperitoneal

Blood supply -Appendicular artery (branch of ileocaecal artery)

Innervation -Sympathetic: superior messenteric plexus

-Parasympathetic: vagus nerve

Lymphatic drainage -ileocolic lymph nodes

 Anatomy of lower GIT
1) Large Intestine

iii) Colon
Ascending Transverse Descending Sigmoid

Location Between caecum Between right Between left colic Between left iliac crest
and right colic colic flexure and flexure and to S3 vertebrae
flexure left colic flexure sigmoid colon (rectum)

Blood supply Ileocolic and right Right, middle and Left colic and Left colic and superior
colic artery & vein left colic artery superior sigmoid sigmoid artery &
Superior artery & vein inferior mesenteric vein
mesenteric vein

Innervation Superior Superior and Superior Superior hypogastric

mesenteric nerve inferior mesenteric hypogastric plexus plexus
plexus plexus Pelvic splanchnic Pelvic splanchnic
nerves nerves

Lymph drainage Right colic lymph Middle colic lymph Left colic lymph Paracolic and epicolic
node node node lymph node
Anatomy of lower GIT
1) Large Intestine

iv) Rectum

Location Between sigmoid colon and anal canal

Blood supply Superior, middle, inferior rectal artery and vein

Innervation -Sympathetic: Lumbar spinal cord (L1 & 2)

-Parasympathetic: Sacral spinal cord (S2 & S4)

Lymphatic drainage Upper: Pararectal node

Middle & Lower: Internal iliac node
Anatomy of lower GIT
1) Large Intestine

v) Anal canal

Location Between anorectal junction and anal canal

Blood supply Superior, Middle, Inferior rectal artery and veins

Innervation Inferior hypogastric plexus and Inferior anal nerve branches of

the pudendal nerve

Lymphatic drainage Internal iliac and superficial inguinal lymph nodes

 Digestion &

02 Absorption of Fat
AIDA IRDINA
 Digestion in mouth & stomach
1. Hydrolysis of TG initiated by lingual and gastric lipases
- attack ester bond of TG and forming free fatty acids
and glycerol

2. The enzyme are active at low pH

3. Short chain FA released will be absorbed directly and

enter the portal vein

4. For long chain FA,it will be further digested in intestine

 Digestion in small intestine
1. It is major site for fat digestion
2. There is presence of bile salts, colipase and
pancreatic lipase
3. Secretion of pancreatic juice will be stimulated by
- passage of acid gastric contents into duodenum
- secretion of secretin and CCK
4. Next, emulsification of TG in duodenum occur,
where large lipid droplet mix with bile salts
forming micelles
5. Micelles have large surface area where it will help
pancreatic lipase to act efficiently, converting
micelles to FA and monoglyceride
6. FFA will be absorbed into mucosal cells
 Absorption, packaging and transport of fatty acids
to tissue

1. Inside enterocyte, monoglycerides and FA will be

re-synthesized into TG
2. TG will be packaged into chylomicrons and it will
be released by exocytosis
3. Nascent chylomicrons then flow into circulation
via lymphatic vessel
4. It will receive Apo CII and Apo-E converting to
mature chylomicron
5. Then, lipoprotein lipase will degrade TG into FA
and glycerol
6. FA will be transported to muscle to used as
energy source and also to adipose tissue to be
stored.
7. Glycerol and chylomicron remnants will taken up
by liver for further degradation.
03
ABSORPTION AND
DIGESTION OF
VITAMIN B2 & B9

NORZULAIKHA
DIGESTION AND ABSORPTION OF WATER SOLUBLE VITAMIN

Hydrolyzed in Absorbed Absorbed Excess

the stomach in the directly into the water-soluble
from protein duodenum portal vein and vitamin are
complexes and transported to excreted
01 found in food
02 jejunum 03 the liver where
they are either
04 through the
kidneys in the
stored or sent urine
out into the
circulation
DIGESTION AND ABSORPTION OF WATER SOLUBLE VITAMIN

Vitamin Absorption Transport, storage and

excretion

B2 Carrier mediated process in the Transported to the liver,

proximal small intestine bound to albumin in plasma,
no storage and excreted
through urine

B9 Active transport and passive Transported as

transport in high dose in the tetrahydrofolate, stored in the
jejunum liver and some excreted in
bile and urine
 VITAMIN B2 (RIBOFLAVIN)

- Act as coenzyme as FMN (flavin

mononucleotide) and FAD (flavin
adenine dinucleotide) in metabolism of
carbohydrate, lipid and amino acid
- Reversibly accepting 2 H atom, catalyze
the oxidation or reduction of a substrate :
help cells use oxygen thus body can
convert source of energy to glucose
- If deficiency, it is seen in rapid turn-over
cells.
- Main dietary source: milk and dairy
products, spinach, broccoli and banana
 VITAMIN B9 (FOLIC ACID)
Deficiency of tetrahydrofolate
- Tetrahydrofolate (active form)
receives 1C from donors such as
serine, glycine and histidine → Diminished synthesis of purines and TMP
transfer them to intermediate for
synthesis of purines and thymidine
monophosphate (TMP)- a pyrimidine Inability of cells (RBC) to make DNA
found in DNA
- Deficiency can cause megaloblastic
Slow DNA replication → less cell division
anaemia and spina bifida
- Source: pea, asparagus, banana and
egg yolk Large red blood cells produced
(macrocytic anaemia)
04 Tropical Sprue
Julia Adriana
 What is Tropical Sprue??
● Conditions occurs in people live or visit tropical areas for
extended periods of time
● Lead to impairs nutrients from being absorbed from intestine
due to damage to lining of small intestine for having too much
of certain types of bacteria in intestines
● Characterized by acute/ chronic diarrhea, malabsorption and ,
multiple nutritional deficiencies especially vitamin B12 and Folic
acid
● Exact causative agent is unknown
THEORY: following an acute intestinal infection episode, there is an
injury to mucosa of small bowel. This leads to enterocyte damage
leading to bacterial overgrowth and retardation of small intestinal
transit.
 RISK FACTORS
● Living in tropical area
● Long periods of travel to tropical destination

CLINICAL FEATURES
● Diarrhea ● Steatorrhea
● Bowel dysfunction ● History of anorexia and
● Watery and foul smelling diarrhea weight loss
● Bloating, crampy abdominal pain and ● Symptoms of anaemia
loud borborygmi (rumbling noise produced by (pallor, fatigue)
gas in the bowel) ● Physical examination :
glossitis, stomatitis,
 COMPLICATION TREATMENT
● Mineral and vitamin deficiencies are ● Plenty of fluids and electrolytes
Common (megaloblastic anaemia) ● Replacement of folate, iro, vitamin
In children: B12, and other nutrients may also
- Delay maturation of bone be needed
- Growth failure ● tetracycline/ bactrim is typically

●
TEST
Enteroscopy
given for 3 to 6 months

● Upper endoscopy
● Biopsy of small intestine
● D-xylose → to see how well the intestines
absorb a simple sugar
● Test of stool → to see if fat absorbed
correctly
● Blood test to measure iron, folate, vitamin B12
● Complete Blood count (CBC)
05 Basis of diarrhea
Aiman Mazlan
 DIARRHOEA
Definition
Diarrhoea is defined as the passage of three or
more loose or liquid stools per day (or more
frequent passage than is normal for the individual).

There are three clinical types of diarrhoea:

● acute watery diarrhoea – lasts several hours or days, and includes cholera;
● acute bloody diarrhoea – also called dysentery; and
● persistent diarrhoea – lasts 14 days or longer.
● Chronic Diarrhea - lasts ≥ 4 weeks

https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease#:~:text=Diarrhoea%20is%
20defined%20as%20the,is%20normal%20for%20the%20individual).
Classification of Diarrhoea
CASE
Diarrhoea for the past 4-5 months -
indicating chronic diarrhoea.

Losing weight 5 kilograms.

Increases when eats

butter, cakes and
fatty meal.
Mechanism of Fatty Diarrhoea
Unabsorbed fats trap
fat-soluble vitamins (A,
D, E, K) and possibly
some minerals, causing
deficiency.

Bacterial overgrowth
results in deconjugation
and dehydroxylation of
bile salts, limiting the
absorption of fats.

Unabsorbed bile salts

stimulate water
secretion in the colon,
causing diarrhea.
Monogram: Chronic Diarrhea :
 Additional Info
● Diarrhoeal disease is the second leading cause of death in children under five years old. It is both
preventable and treatable.
● Each year diarrhoea kills around 525 000 children under five.
● A significant proportion of diarrhoeal disease can be prevented through safe drinking-water and
adequate sanitation and hygiene.
● Globally, there are nearly 1.7 billion cases of childhood diarrhoeal disease every year.
● Diarrhoea is a leading cause of malnutrition in children under five years old.
06
Correlation between
diarrhea and fatigue
Izzah Wadihah
Causes of fatigue in diarrhea

01 02 03
Dehydration Lack of nutrients Imbalance in gut bacteria
 Causes of fatigue in diarrhea

Dehydration Lack of nutrients

● Loss of fluids and electrolytes ● Diarrhea will cause less

from body due diarrhea can lead nutrients being absorbed to
to dehydration the intestines
● Dehydration will lead to ● Lack of nutrients can lead to
hypovolemia (low blood volume) decreased energy levels in
that cause low cardiac output body
● Thus, less blood is sent to brain
which cause increased in heart
pumping and eventually lead to
fatigue as heart is working
overtime
 Causes of fatigue in diarrhea

Imbalance in gut bacteria

● Gut dysbiosis (the overgrowth of

pathogenic bacteria and
inadequate amounts of good
bacteria) might play a role in
chronic fatigue syndrome
● An unhealthy gut microbiome
eventually could also leads to
fatigue after diarrhea.
07
TYPES OF STOOL
ALIA AZLAN
 BRISTOL STOOL CHART

- The Bristol Stool Chart is widely used as a research tool to evaluate the
effectiveness of treatments for various diseases of the bowel.
- The chart is used to describe the shapes and types of stools.
- Ranging from the hardest to the softest
 BRISTOL STOOL CHART
- Type 1 has the appearance of separate hard lumps, while type 2 is
sausage-shaped but lumpy. Both types could indicate constipation, as these
stools are hard, dry, and difficult to pass. They may also be darker in color.
This occurs when food passes too slowly through the digestive system and
the colon absorbs too much water.

- Type 3 has a shape similar to a sausage but with cracks on the surface,
while type 4 has a comparable appearance to type 3 but with a smooth and
soft surface.

- Type 5 stools are soft blobs with clear-cut edges that a person can pass
easily. Some may also consider this type to be typical in those without bowel
issues, while others may suggest it is too loose and may imply diarrhea.
 BRISTOL STOOL CHART
- Type 6 is a mushy stool that appears to consist of fluffy pieces with ragged
edges, while type 7 is entirely liquid with no solid pieces. These types of
stools may suggest a person is experiencing diarrhea, as the stools are
loose. They may also be lighter in color. This is due to passing the stool
through the digestive system too quickly and the bowel is unable to absorb
water.

TYPE 1-2 - indicate constipation

TYPE 3-4 - ideal stool
TYPE 5-7 - may indicate diarrhea and urgency
 CAUSES OF

08 DISTENDED
ABDOMEN
MIQAEL AIMAR THAQIF TEH
 Causes of distended abdomen
Distended abdomen is when the
abdomen is abnormally swollen
outward.
● The abnormality can be seen
visually and measured
physically
● People who undergo this
abnormality can sense a
feeling of bloatedness or
fullness
 Causes of distended abdomen
This can be due to:
● Ascites - a buildup of fluid in the abdomen
● Obstruction of small or large bowel - buildup of gas or
waste in bowel
● Inflammatory bowel disease - chronic inflammation in the
bowel
● Gastroparesis - partial paralysis of the stomach - buildup
of digestive contents
● Pregnancy
● Organ enlargement - hepatomegaly, splenomegaly
● Malabsorption syndrome - lactose, carbohydrates, fats
● Herniation - bulging through opening or weakness in
muscle or tissue barrier
 Causes of distended abdomen
Based on Farah Saad’s case, she
complained of occasional
abdominal distension but no
abdominal pain.
● The occasional abdominal
distension can be due to
malabsorption of fats
causing buildup of
unabsorbed fats leading to
abdominal bloating,
diarrhoea, foul smelling stool,
weight loss and stool hard to
flush
● The abdominal pain is usually
due to gas pain or
inflammation
 CAUSES OF
09 MALABSORPTION
NUR FATINAH ‘IZZATI ABDUL MAJID
Causes of malabsorption:
Causes of malabsorption:
Tropical sprue:
Coeliac disease: