11 Gastrointestinal Diseases

8/7/2019 11 Gastrointestinal Diseases

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Gastrointestinal diseasesGastrointestinal diseases


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Categories of symptoms

Categories of symptoms

1. Symptoms of organic disease

- achalasia, duodenal ulcer, celiac disease,

ulcerative colitis, regional enteritis2. Psychophysiologic disorders

- increased peristalsis after stress

3. Symptoms of psychiatric disease

- constipation, clears after antidepressantmedication

- globus hystericus, clears after tranquilizers


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Common functional disorders of theCommon functional disorders of the

GI tractGI tract

I. Disorders of swallowing

A. Globus hystericus

B. Esophageal spasm (peristalsis)

C. Heartburn (incompetence of inf sphyncter)II. Disorders of stomach and duodenum

A. Pyloric dysfunction (dyspepsia, nausea, vomiting)

B. GI bleeding

III. Disorders of the colon (irritable colon syndrome)

A. Pain and constipation

B. Intermittent diarrheaIV. Disorders of the anus

A. Fecal incontinence

B. Proctalgia fugax

C. Pruritus ani


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Diagnosis

Diagnosis

History taking

! Stressful life situations, effect of

stress cessation

! Social history

Physical examination

Lab studies


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Example: Life chart of patient

Example: Life chart of patient

Age Life situation Bowel function

13-20 Home, father died Irregular constipation20-23 Near home, nursing training Steadily constipated

23-27 Away from home, private Regular, no laxatives

28 Mother ill, terminal illness Severely constipated

Patient cared for her at home

29-30 Returned to private duty Regular, no laxativesnursing

31-36 Worked as nurse anesthetist Severely constipated


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Globus hystericusGlobus hystericus Sensation of lump in the throat

Related to stress (choked up)

Careful history! for diff dg:

- symptomatic esophageal spasm

- gastroesophageal reflux

- myastenia, polymyositis

- mediastinal compression

Symptoms do not worsen during swallowing Relieved by eating, drinking

Esophageal manometry

Tr: antidepressives


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Esophageal spasmE

sophageal spasm Neurogenic disorder of esophageal

motility with phasic nonpropulsive

contractions Substernal chest pain, dysphagia for

liquids and solids

X-ray poor progression of bolus

Esomanometry lower esoph sphincterpressure impaired

Tr: Ca-ch blockers, dilation


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Heartburn

Heartburn

Caused by gastroesophageal reflux, withincompetence of lower esophageal sphincter

Dg: -history

- X-ray Trendelenburg- esophagoscopy

- esomanometry

- biopsy

Tr: - elevate head of bed- avoid stimulants of secretion

- avoid specific foods, drugs, smoking

- antacid 1h after meals

- increase sphincter pressure (metoclopramide)


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Dyspepsia

Dyspepsia

Indigestion, fullnes or pain localized inupper abdomen of chest

Abdominal distension, borborygmus Association of symptoms: duodenitis,

pyloric dysfunction, motility disturbances,cholelitiasis

!psychologic causes somatization ! Gastric infection with Helicobacter pylori

Tr: reassurance, continued observation


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GI bleedingGI bleedingCommon causes upper GI tract:

- Duodenal ulcer

- Gastric erosions

- Varices

- Gastric ulcer

- Mallory-Weiss tear- Erosive esophagitis

- Angioma


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GI bleedingGI bleedingCommon causes lower GI tract:

- Diverticular disease

- Colonic carcinoma

- Colonic polyps

- Inflammatory bowel disease

- Colitis (radiation, ischemic)

- Internal hemorrhoids

- Anal fissuresSmall bowel lesions:

- Meckels diverticulum

- Neoplasms


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GI bleedingGI bleeding Vomiting of blood=hematemesis

Passage of black stool=melena

Passage of blood=hematochezia

- Symptoms depend on source and rate of

bleeding:

- shock, massive- anemia, occult

- ortostatic changes in BP and HR


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GI bleedingGI bleeding Dg

- history do not forget NSAIDS

- phys exam: assess vital signsexclude nose/throat

exclude trauma

exclude liver disease

digital rectal exam

Nasogastric aspiration

Panendoscopy

Emergency send to ICU


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Peptic ulcerP

eptic ulcer Dg

- chronic recurrent course

- symptoms vary with age and location(asymptomatic 1/2 characteristic steadyburning pain in epigastrium, relieved byantacids/milk, period free of pain after meals)

- endoscopy-cytologic search

- X-ray studies with barium- gastric secretory studies (suspected Zollinger-Ellison syndrom)


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Peptic ulcerP

eptic ulcer Treatment

- nonabsorbable antacids Al (OH)3, Mg(OH)2 1h after meals

- H2 receptor antagonists ( cimetidine 800, ranitidine 300,famotidine 40, nizatidine 300 at bedtime) 6 wk, repeatendoscopy

- sucralfate protective coating 1g tid

- inhibitors of proton pump omeprazole 20-80 mg /day,single dose or bid 2-4 wk DU, 6 wk GU

- Pg E2, misoprostol prevention of ulcers caused byN

SAIDS

! H2 antagonists of no use in acute pancreatitis

! Persistent abdominal symptoms after 2 wk of therapy requirediagnostic reevaluation


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Peptic ulcerP

eptic ulcer H. pylori, a spiral-shaped bacterium present in more than 90% of

patients with intestinal (duodenal) ulcers and in more than 80% ofthose with stomach (gastric) ulcers

4 drug regimensBi+Metro+Amoxi+H2Bl

Bi+Metro+Clarithro+PPI

3 Drug regimens

Clarithro+Metro+PPI

Amoxi+Clarithro+PPITetra+Metro+Sucralfate

All taken for 2 weeks


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Peptic ulcerP

eptic ulcer Adjunctive treatment

- diet avoid pepper, spicy foods,

fatty foods, coffee, alcohol- quit smoking

- consider surgery in recurrences

- hospitalization if complicationsoccur


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Peptic ulcerP

eptic ulcer Complications

- penetration

- perforation

- hemorrhage

- obstruction


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Acute pancreatitis

Acute pancreatitis

Dg

- Severe abdominal pain that radiates to the

back- Patient acutely ill, sweating

- HR 100-140, BP low, shock

- Sensorium blunted, semi-coma

- Upper abdominal distension- Peritoneal irritation

- Hypoactive bowel sounds


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Acute pancreatitis

Acute pancreatitis

Diff dg

- Perforated G/D ulcer

- Mesenteric infarction- Intestinal obstruction with strangulation

- Dissecting AO aneurism

- Biliary colic

- Appendicitis- Diverticulitis

- Ectopic pregnancy


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Acute pancreatitis

Acute pancreatitis

Lab

- Serum amylase and lipase elevated

- Increased WBC 12,000-20,000

- Increased Ht 50% due to fluid losses

- Hyperglycemia


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Acute pancreatitis

Acute pancreatitis

Investigations

- Supine and plain films of the

abdomen

- Chest Xray

- US

- CT


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Acute pancreatitis

Acute pancreatitis

Treatment

- Severe acute pancreatitis send to ICU

- Mild edematous pancreatitis- maintain pt in fasting state until cessationof abdominal tendetness, normalization ofamylase and return of hunger

- infuse sufficient iv fluids to prevent

hypovolemia and hypotension- insert nasogastric tube to remove gastric

fluid and air if ileus is present


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Diarrhea

Diarrhea

Dg

History

place, time, circumstances of onset, duration, severity- presence of overt or occult blood in stool

- evidence of steatorrhea

- changes of weight

- use of dietetic products/appetite

- Presence of rectal tenesmus

! Diarrhea is a symptom. Find underlying disorder


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Diarrhea

Diarrhea

Causes

- Osmotic diarrhea (lactase deficiency,sucrose, mannitol, chewing-gum)

- Secretory diarrhea (enteropathic viruses,bile acids, VIPomas)

- Malabsorbtion (nontropical sprue)

- Exudative diarrhea (mucosal diseases-ulcerative colitis, regional enteritis, TB)

- Altered intestinal transit (gastric resection,surgical by-pass, laxatives)


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Constipation

Constipation

Dg

- acute/chronic

- Ac: consider mechanical bowelobstruction, adynamic ileus, careful drug

history (antacids, anticholinergics, Bi, Fe)

-Cr: irritable bowel, colonic inertia,megacolon, systemic disorders,

neurologic disorders


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Constipation

Constipation

Tr

- Diet high fiber

- Bulking agents methylcellulose

- Laxatives

- Osmotic agents lactulose, sorbitol- Secretory stimulants senna,

cascara


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Anorectal dysfunction

Anorectal dysfunction

Procedures:

- Perform digital rectal exam/anuscopy

- Visually inspect stool

- Perform guaiac test on stoolDg

- External/internal hemorrhoids

- Anal fissure

- Anal fistula

- Perirectal abscess

- Peutz-Jeghers syndrome- Rectal prolapse

- GI bleeding

- Parasites


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Visually inspect stool

Visually inspect stool

Mucus- inflammation

Bright red blood GI bleeding

Black, sticky, guaiac + = melena

Greasy = steatorrhea

Parasites


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Guaiac testGuaiac test Place a sample of stool on guaiac

card, place a drop of reagent and

observe change of color

Blue = presence of hemoglobin in

stool = GI bleeding

11 Gastrointestinal Diseases

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