Gastroenterology & Its Main Clinical Syndrome
Transcript of Gastroenterology & Its Main Clinical Syndrome
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Professor T.A. Dronova
LectureGASTROENTEROLOGY
MAIN CLINICAL SYNDROMES
KURSK STATEKURSK STATE
MEDICAL UNIVERSITYMEDICAL UNIVERSITY
Propaedeutics of InternalPropaedeutics of Internal
DiseasesDiseasesDDepartentepartent
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UPPER !ASTR"ENTISTINAL #LEEDIN!
Upper GI bee!"n# $ bee!"n# fro% es"on
of esop&a#us' sto%ac&' !uo!enu%
(above Tre"ts) "#a%ent*
Upper GI bee!"n# features+
,e%ate%es"s (vo%"t"n# of boo! or
cofee #roun! vo%"t"n#*
Meena Clinical features depend on rapidity & amount of
blood lost
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!ASTR"ENTISTINAL#LEEDIN!
,e%ate%es"s $ vo%"t"n# of boo! (br"#&t re! orcoffee #roun!*
Meena $ tarr- bac' st"c-' fou s%e"n# stoo
(ot&er stoo !arness $ "ron / b"s%ut& * Spec"a features+
a* appro0"%ate- 12 % of boo! "s re3u"re! topro!uce s"n#e bac stoo
b* t&e boo! oss 4 12 % pro!uces %eena for%ore t&an 5 !a-s
c* to pro!uce %eena t&e boo! %ust be "n t&e#ut for 6 &ours
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UPPER !ASTR"ENTISTINAL #LEEDIN!
Etiolo$%
Co%%on causes 7
C&ron"c !uo!ena ucer
C&ron"c #astr"c ucer
Gastr"c eros"ons (eros"ve #astr"t"s*8ar"ces
Maor-$9e"s tear
Esop&a#"t"sDuo!ena eros"ons
Sto%ac& cancer
M"sceaneous
:;
:2
:2
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UPPER !ASTR"ENTISTINAL #LEEDIN!
Su&se'uent cause e(aluation
Pept"c ucer !"sease> ep"#astr"c pa"n /&eartburn &"stor-
Gastr"c eros"ons> NSAIDs orcort"costero"!s us"n#
L"ver c"rr&os"s> s"#ns of c&ron"c "ver!"seases (?aun!"ce' pa%ar er-t&e%a'
euon-c&"a' sp"!er nev"'&epatospeno%e#a- / asc"tes*
Maor-$9e"s s-n!ro%e$ &"stor- offorcefu vo%"t"n# before &e%ate%es"s
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UPPER !ASTR"ENTISTINAL #LEEDIN!
Clinical features
@ee!"n# fro% upper GIT %a- present "t&
&e%ate%es"s (rap"! bee!"n# presents as
&e%ate%es"s * or %eena (so bee!"n#
presents as %eena* ,e%ate%es"s $ vo%"t"n# of boo!
Cofee #roun! vo%"t"n# ("f boo! re%a"ns "n
sto%ac&' "t beco%es part"a- !"#este! /
appears bron "n t&e vo%"t*
Meena $ passa#e of bac stoos (after as "tte
as ;2$
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Se(ere &leedin$
S-%pto%s+
eaness' fa"ntness' nausea' seat"n#'
restessness / !"sor"entat"on
S"#ns+ postura &-potens"on 4
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UPPER !ASTR"ENTISTINAL #LEEDIN!Initial assessent ) &lood lost estiation C"n"ca ?u!#e%ent of !e#ree or rate of
bee!"n#
@P' puse / postura c&an#es (ort&ostat"c !rop
"n boo! pressure 4 "n!"cat"on of
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UPPER !ASTR"ENTISTINAL #LEEDIN!
Initial assessent ) &lood lost estiation
In"t"a &e%o#ob"n eve / &e%atocr"t $ not
atere! unt" :$5= &ours (re!uce! &e%atocr"t
on a!%"ss"on to &osp"ta su##ests c&ron"c
bee!"n# pr"or to acute ep"so!e* R"se! boo! urea "t& nor%a seru% creat"n"ne
> oss of at east < "ter "n!"cat"on
Naso#astr"c tube passa#e $ assess"n#
pers"stent rate of bee!"n#
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UPPER !ASTR"ENTISTINAL #LEEDIN!
In(esti$ations
En!oscop-
Seect"ve ab!o%"na an#"o#rap&-
Urea' creat"n"ne' eectro-tes
L"ver funct"on tests' protro%b"n
@oo! #roup"n# / cross %atc&"n#
@oo! test
Ra!"onuc"!e scan
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UPPER !ASTR"ENTISTINAL #LEEDIN!
Mana$eent
Intravenous access' o0-#en' se!at"on
@oo! vou%e repace%ent
En!oscop-
P&ar%acoo#"ca %easures+
Proton pu%p "n&"b"tor
Octreot"!e
Sur#er-
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UPPER !ASTR"ENTISTINAL #LEEDIN!
Eer$enc% ana$eent
,"stor- / e0a%"nat"on
Puse / @P %on"tor"n# &af$&our-
@oo! e0a%"nat"on for &e%o#ob"n' urea' cret"n"ne'
eectro-tes' boo! #roup"n# / cross %atc&"n# I8 "ne ("n br"s bee!"n# > centra "ne*
Nor%a sa"ne / boo! trasfus"on ("n!"cat"ons+ s&oc >
@P B
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Lo*er $astrointestinal &leedin$
Loer GI bee!"n# "s !ef"ne! as bee!"n#
ar"s"n# beo t&e "#a%ent of Tre"tF+
s%a "ntest"ne / coon
%a?or"t- of cases ar"se fro% coon /
part"cuar- t&e anorecta re#"on
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Lo*er $astrointestinal &leedin$
Etiolo$%Youn# pat"ents (beo ;2 -ears*+
Anorecta !"sease (&e%orr&o"!s' ana f"ssure*
Infect"ous co"t"s (S&"#ea' E. co"*
Infa%%ator- boe !"sease (ucerat"ve co"t"s*
O! pat"ents (above ;2 -ears*+
D"vert"cuos"s
An#"o!-spas"as
Neopas%s
Isc&e%"c co"t"s
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Lo*er $astrointestinal &leedin$
Si$ns Pa"ness bee!"n#$ "nterna &e%orr&o"!s'
!"vert"cuos"s' an#"o!-spas"a
@ee!"n# "t& pa"n$ "n ana f"ssure' "sc&e%"cco"t"s / "nfa%%ator- boe !"sease
,ae%atoc&eF"a$ br"#&t re! boo! fro%rectu%+
bee!"n# fro% ana / recta es"ons "n&e%orr&o"!s' f"ssures' f"stuas / carc"no%as
a%ount of boo! var- fro% fe !rops to%ass"ve bee!"n#
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+aeatoc,e-ia
It "s a passa#e of re! (or %aroon* boo! fro%
t&e rectu%' usua- s"#n"f"es bee!"n# fro% a
source !"sta to t&e "#a%ent of Tre"tF (beteen
!uo!enu% / s%a "ntest"ne* "t can aso occur fro% %ass"ve upper
#astro"ntest"na bee!"n# (fro% esop&a#us'
sto%ac& / !uo!enu%*
Appearance of blood in stool depends not
only on bleeding site but also on hemorrhage
rate & rapidity of transit
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Lo*er $astrointestinal &leedin$
Patient e(aluation D"vert"cuos"s+ pa"ness %aroon or br"#&t re!
&e%atoc&eF"a "n pat"ent 4 ;2 -ears of a#e' bee!"n#stops spontaneous-
An#"o!-spas"a+ pa"ness bee!"n# "n pat"ent 4 52 -ears
Neopas%+ ben"#n / %a"#nant > usua- "t& c&ron"coccut bee!"n# Infa%%ator- boe !"sease (ucerat"ve co"t"s*+ !"arr&ea
"t& occut bee!"n# or recurrent &e%atoc&eF"aassoc"ate! "t& ab!o%"na pa"n' tenes%us / ur#enc-
Anorecta !"sease &e%orr&o"!s > pa"ness bee!"n#%"0e! "t& stoo or !r"pp"n# "nto to"et bo' pa"nfus%a bee!"n# "n ana f"ssure
Isc&e%"c co"t"s > e!er- pat"ent "t& aterosceros"s >boo!- !"arr&ea "t& %"! ab!o%"na cra%ps
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C"L"NIC DISEASE
Rectal &leedin$
D"a#nost"c stoo appearance+
Blood coating exterior of formed stool - lesion in
anal canal or rectum
Blood admixed with feces - bleeding source higherin colon
Brisk hemorrhage from colon or distal small
intestine - passage of fresh blood (hematochezia): fresh blood & clots - lesion in left colon
dark, maroon-colored blood - bleeding from right
colon
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Lo*er $astrointestinal &leedin$
Dia$nosis Se3uence of !"a#nost"c toos+ ev"!ence of anorecta !"seases' I"nfa%%ator- boe
!"sease or "nfect"ons co"t"s
:. E0cu!e upper GI bee!"n# > naso#astr"c tube
=. Tec&net"u%$ scan > to !etect act"ve bee!"n# course
. An#o"#rap&- (c&o"ce %et&o!* > rap"! oca"Fat"on
;. Coonoscop- ("f bee!"n# stops* > "!ent"f"cat"on of
an#"o!-spaF"a' t"ssue b"ops-
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P,%sical e.aination
in colonic diseases D"#"ta recta e0a%"nat"on (per"ana'
sp&"nter"c / a%puar- es"ons' prostat"c /
uter"ne abnor%a"t"es' recta %asses /
%etastat"c tu%or "n per"recta t"ssues $@u%er)s s&ef
Heca %ater"a on #ove $ "%%e!"ate test "t&
#ua"ac$"%pre#nate! car!s for occut boo!
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@e! rest' se!at"on / transfus"on
Stop asp"r"n / ot&er NSAIDs
T&erapeut"c coonoscop-+ en!oscop"c
eectrocoa#uat"on of an#"o!-spas"a
Intra$arter"a vasopress"on or e%bo"Fat"on
(27 effect"ve "n !"vert"cuu% or
an#"o!-spas"a* Sur#er-
Lo*er $astrointestinal &leedin$
Mana$eent
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"ccult $astrointestinal &leedin$
Loss of s%a a%ounts of boo! "nto GIT >
present "n stoo' but no &e%atoc&eF"a or
%eena
Met&o!s for !etect"on+ Pos"t"ve feca occut boo! test
Iron !ef"c"enc- ane%"a "n a!ut
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"ccult $astrointestinal &leedin$
Etiolo$%
A causes of upper / oer #astro"ntest"nabee!"n# > co%%on causes+
Tu%ors+ ben"#n or %a"#nant tu%ors of an-
s"te "n GIT espec"a- > coon canser Pept"c ucer / esop&a#"t"s
NSAIDs
An#"o!-spas"a
Infect"ons (&oo or% > %ost co%%on cause*
Ma?or causes+ ceca carc"no%a /an#"o!-spas"a (arter"ovenous %afor%at"on&"c& can be v"s"be on coonoscop-*
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"ccult $astrointestinal &leedin$
In(esti$ations
9eber)s #ua"ac test>
!etect"on of &e%o#ob"n pero0"!ase+
=$; # of feces %"0e! "t& stron# acet"c ac"!
(se%""3u"! paste* > %"0ture stan!s for =2%"n.
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"ccult $astrointestinal &leedin$
In(esti$ations
Gre#ersen)s benF"!"ne test>
Propert- of &e%o#ob"n to cata-se o0"!at"on$
re!uct"on react"ons+
,-!ro#en p"ro0"!e
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#lood in stool
@oo! %"0e! "t& stoo+ eft s"!e! coon"c
tu%or' "nfa%%ator- boe !"sease' !"vert"cuar
!"sease' "nfect"ve co"t"s / an#"o!-spas"a
Hres& boo! "n s%a a%ounts+ &e%orr&o"!s'Cro&n)s !"sease of t&e anus' carc"no%a of t&e
rectu%
Severe bee!"n# (rare* + !"vert"cuar !"sease /
"sc&e%"c co"t"s
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Difference &et*een upper /
lo*er $astrointestinal &leedin$
Heatures Upper#astro"ntest"nabee!"n#
Loer#astro"ntest"nabee!"n#
S"te Above Tre"ts)"#a%ent (esop&a#us'sto%ac&' !uo!enu%*
@eo Tre"ts)"#a%ent (s%a"ntest"ne / coon*
Presentat"on ,e%ate%es"s
Cofee #roun!vo%"t"n#
Meena
,e%atoc&eF"a
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Difference &et*een upper /
lo*er $astrointestinal &leedin$
Heatures Upper#astro"ntest"nabee!"n#
Loer#astro"ntest"nabee!"n#
Naso#astr"casp"rat"on
@oo! Cear fu"!
@oesoun!s
,-peract"ve Nor%a
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MALA#S"RPTI"N
Maabsorpt"on $ "na!e3uate transport of one
or %ore of const"tuents of nor%a !"et fro%
"ntest"na u%en across "ntest"na ep"t&e"u%
"nto porta c"rcuat"on CLINICAL HEATURES+
D"arr&ea
Ab!o%"na pa"n D"stens"on
9e"#&t oss
Nutr"t"ona !ef"c"enc"es
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Nutrient a&sorption
SitesDuo!enu%+iron, calcium, magnesium,folic acid, water soluble itamins, amino
acids, monosaccharides
Je?unu%+fatt! acids, amino acids,
monosaccharides, water soluble itamins
Ieu%+ monosaccharides, fatt! acids,
amino acids, fat soluble itamins (", #, $,
%), itamin B' & conugated bile salts
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Nutrient a&sorptionP,%siolo$% 0 1 p,ases
Lu%"na p&ase+ &-!ro-s"s /
soub""Fat"on of nutr"ents
Mucosa p&ase+ furt&er brea!on ofnutr"ents / transfer "nto ce
Transport p&ase+ re%ova of nutr"ents
"nto vascuar or -%p&at"c c"rcuat"on
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23 Intraluinal ala&sorptionDisoders
Pancreat"c "nsuff"c"enc-+
C&ron"c pancreat"t"s
C-st"c f"bros"s (autoso%a !"sease*
Carc"no%a of pancreas
Def"c"enc- of b"e ac"!s+
Entero&epat"c c"rcuat"on "nterrupt"on (resect"on orter%"na "eu% !"sease*
S%a "ntest"ne coon"Fat"on "t& bacter"a &"c&
!econ?u#ate b"e ac"!s (sta#nant oop s-n!ro%e* Uncoor!"nate! #astr"c e%pt-"n#+
Gastroenterosto%-
Part"a #astrecto%-
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43 Mucosal p,ase ala&sorptionDisoders Genera"Fe! %ucosa abnor%a"t"es(&"stoo#"ca-
abnor%a %ucosa*+
Coe"ac !"sease (#uten$sens"t"ve enteropat&-*
Tubercuos"s
Trop"ca sprue
L-%p&o%a
Ra!"at"on enter"t"s
9&"ppe)s !"sease (%acrop&a#es "nf"trat"on* Maabsorpt"on of spec"f"c substances(&"stoo#"ca-
nor%a %ucosa*+
Lactase !ef"c"enc-
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13 Transport p,ase ala&sorption
Disoders
8ascuar+ vascu"t"s' at&erosceros"s
L-%p&at"c+ -%p&an#"ectas"a'"nf"trat"ons
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Mala&sorption S%ndroe
S%ptos
GIT s-ste%
Gen"tour"nar- s-ste%
,e%atopoet"c s-ste%Muscuoseeta s-ste%
Nervous s-ste%
S"n
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MALA#S"RPTI"N
Nutr"t"ona!ef"c"enc"es
Heatures
Hats Steatorr&ea' frot&-stoos' ater- !"arr&ea'e"#&t oss
Carbo&-!rates Hatuent !-speps"a(borbor-#%us*'
ab!o%"na !"stens"on'fatus' ater- !"arr&ea
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MALA#S"RPTI"N
Nutr"t"ona!ef"c"enc"es
Heatures
Prote"n 9e"#&t oss' %usce ast"n#'
&-poabu%"nur"a' oe!e%a'eucon-c&"a
Ho"c ac"! Macroc-t"c'
%e#aobast"c ane%"a'#oss"t"s' ora %ucosaucerat"on "n fo"c ac"!
!ef"c"enc-
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MALA#S"RPTI"N
Nutr"t"ona!ef"c"enc"es
Heatures
8"ta%"n @
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MALA#S"RPTI"N
Nutr"t"ona!ef"c"enc"es
Heatures
8"ta%"n C @ee!"n# ten!enc-
8"ta%"n A Ho"cuar&-pereratos"s'0eropt&a%"a' n"#&tb"n!ness
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MALA#S"RPTI"N
Nutr"t"ona!ef"c"enc"es
Heatures
8"ta%"n D /
Cac"u%
Osteo%aac"a(r"cets*' pro0"%a%-opat&-'paraestes"a' tetan-
8"ta%"n K Purpura'&e%orr&a#es(bru"s"n# / bee!"n#*
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MALA#S"RPTI"N
Nutr"t"ona!ef"c"enc"es
Heatures
Iron ,-poc&ro%"c ane%"a'c&e"os"s' spoon$s&ape!na"s (o"on-c&"a*'
apt&ous ucers
So!"u% Muscuar eaness'cra%ps
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MALA#S"RPTI"N
Nutr"t"ona!ef"c"enc"es
Heatures
Potass"u% Hacc"!"t-'arr&-t&%"as
Ma#nes"u% Muscuar eaness'paraestes"a' tetan-
9ater Nocturna !"ures"s
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MALA#S"RPTI"N
Nutr"t"ona!ef"c"enc"es
Heatures
"nc Poor taste' !er%at"t"s'poor oun! &ea"n#
@"e sats 9ater- !"arr&ea
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!ASTRIC "UTLET "#STRUCTI"N
5PYL"RIC STEN"SIS6
Et"oo#-+
Pept"c ucer "n t&e re#"on of p-orus
(%a- ea! to #astr"c outet obstruct"on*
!ue to e!e%a' spas%' f"brous str"cture
Duo!ena ucer
Carc"no%a of antru%
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!ASTRIC "UTLET "#STRUCTI"N
5PYL"RIC STEN"SIS6
irst - narrowing is compensated b! h!pertroph!
of the gastric muscles
*ater - stomach becomes distended, food sta!s
inside for longer period & fermentation &putrefaction occurs in the stomach
"bsorption of water impaired
+pset of water-salt balance causing generaldeh!dration of the bod! & decrease of chloride
content in the blood & urine
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!ASTRIC "UTLET "#STRUCTI"N
5PYL"RIC STEN"SIS6
Lon# &"stor- of pept"c ucer "t& pro%"nent
nausea / vo%"t"n#
9"t&out s-%pto%s of pept"c ucer > p-or"c
carc"no%a
8o%"t"n# $ str""n# re"ef
8o%"tus+ aa"ne react"on (presence ofa%%on"a co%poun!s* of foo! part"ce &ave
been eaten : &ours or 4 prev"ous-
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!ASTRIC "UTLET "#STRUCTI"N5PYL"RIC STEN"SIS6Clinical features per%anent pa"n (&"c& "ntens"f"es at n"#&t*
eructat"on "t& rotten e## "n!
vo%"t"n# "t& foo! t&at as "n#este! severa
!a-s a#o const"pat"on "s aternate! "t& !"arr&ea
t&rou#& "rr"tat"on of t&e s%a "ntest"ne b-fer%ente! foo! !"sc&ar#e! "nto "t fro% t&e
p-orus t&at "s opene! b- "ntens"f"e!per"stas"s
aaos"s !eveops "f ar#e a%ount of ,C "sost "n vo%"t"n#
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!ASTRIC "UTLET "#STRUCTI"N5PYL"RIC STEN"SIS6Clinical features
9ast"n# (cac&e0"a* !ue to un!ernour"s&%ent
De&-!rat"on
E0a%"nat"on of t&e ep"#astr"u%+ per"stas"s /
ant"per"stat"c contract"ons of t&e sto%ac& $v"s"be #astr"c per"stas"s(per"stas"s ave
pro#ress"n# fro% eft &-poc&on!r"u% /
ep"#astr"c re#"on toar!s r"#&t u%bar re#"on*
Late spas&"n# soun! (,"ppocrates) s"#n* 4 5$6&ours after ast %ea or !r"n ("n &eat&- person
spas&"n# soun! (succus"on* B < &our after
%eas because #astr"c e%pt-"n# "s rap"!*
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!ASTRIC "UTLET "#STRUCTI"N5PYL"RIC STEN"SIS6
In(esti$ationAsp"rat"on of sto%ac& contents+ vou%e
4
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!ASTRIC "UTLET "#STRUCTI"N5PYL"RIC STEN"SIS6
In(esti$ationEn!oscop-+
Les"on at p-orus
Increase "n fast"n# res"!ue of sto%ac&foo!
Seru% eectro-tes !epet"on
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!ASTRIC "UTLET "#STRUCTI"N
5PYL"RIC STEN"SIS6
Mana#e%ent
Asp"rat"on+
Not&"n# per os
:$ &our- asp"rat"on for =$ !a-s ("f asp"rat"onvou%e !ecrease! > fu"! b- %out&*
I8 fu"! > re&-!rat"on
8"ta%"ns Sur#er-
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INTESTINAL "#STRUCTI"N
: t-pes of "ntest"na obstruct"on
S"%pe or !-na%"c+ per"stas"s or"n#
a#a"nst obstruct"on a#ent "n t&e "ntest"na
u%en' "n t&e a or outs"!e t&e a (feca"%pact"on' str"cture or a!&es"on*
Stran#uat"on or a!-na%"c+ per"stas"s ceases
/ no propus"ve ave occurs $ "t& "ntest"na
boo! supp- &en t&e boe "s trappe! or
t"ste! (para-t"c "eus or %esenter"c vascuar
occus"on*
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INTESTINAL "#STRUCTI"N
Etiolo$%
Lu%"naobstruct"on
Heca "%pact"onGastone "eus9or%s (ascar"!"as"s*
Intr"ns"ces"ons ofboe a
Tu%ors of ar#e "ntest"neStr"ctures (tubercuos"s' Cro&n)s!"sease*Intussuscept"on
E0str"ns"cco%press"on
A!&es"on,ern"as8ovuus
Para-t"c "eus Per"ton"t"s
Postoperat"ve8ascuar
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INTESTINAL "#STRUCTI"N
Clinical features
Pa"n+
Co"c- pa"n "n %ec&an"ca obstruct"on
Du constant pa"n "n para-t"c "eus8o%"t"n#+
Cop"ous > "n &"#& s%a boe
obstruct"onLate or absent > "n oer s%a boe or
coon obstruct"on
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INTESTINAL "#STRUCTI"N
Clinical features
Ab!o%"na !"stent"on D"stent"on conf"ne! to so%e oops of boe $
r"!#es across t&e ab!o%en for%"n# La!!erPattern) $ v"s"be "ntest"na per"stas"s$ !"sta
s%a boe obstruct"on+ step a!!er for%ofper"stas"s aves (%ot"e s%a "ntest"ne* "nu%b""ca re#"on
Later !"ffuse !"stent"on > "n!"cat"on of c&ron"c
ar#e boe obstruct"on or para-t"c "eu% Co%pete obstruct"on $ feaces / fatus not
passe! H"rst $ "ncrease! boe soun!s' ater $ absent
per"stat"c soun!s
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INTESTINAL "#STRUCTI"N
In(esti$ation
H"n#er e0a%"nat"on of rectu%+baoone! / e%pt- rectu% (Obu&ov)s
&osp"ta or Greov)s s"#n*
Pa"n $ra- ab!o%en ("n erect / sup"ne
pos"t"on* $ #aseous !"stent"on /"ntest"na fu"! eves (Ko"ber)s cups $
&or"Fonta fu"! eve / #as bubbe*
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INTESTINAL "#STRUCTI"N
Mana#e%ent
Not&"n# per os
Deco%press"on (#astro"ntest"na !ra"na#ev"a naso#astr"c tube*
I8 fu"! / eectro-tes
Ant"b"ot"cs
Sur#er-
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ACUTE A#D"MEN
ACUTE A@DOMEN> a ter% use! to
!ef"ne a #roup of ab!o%"na
con!"t"ons "n &"c& pro%pt sur#"ca
treat%ent %ust be cons"!ere!
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ACUTE A#D"MEN
CAUSES@oe
Acute appen!"c"t"s
Perforate! pept"c ucer or ab!o%"na v"scus
D"vert"cuar !"sease
Intest"na obstruct"on / stran#uat"on
Mece)s !"vert"cuu%
Ter%"na "e"t"s (Yers"n"a "nfect"on*
ACUTE A#D"MEN
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ACUTE A#D"MEN
CAUSES8ascuar
Acute vascuar "nsuff"c"enc-
Rupture! aort"c aneur-s%
G-necoo#"ca
Rupture! ectop"c pre#nanc-
Rupture! ovar"an c-st Acute sap"n#"t"s
ACUTE A#D"MEN
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ACUTE A#D"MEN
CAUSESOt&ers
C&oec-st"t"s
Acute pancreat"t"s
Acute %esenter"c a!en"t"s
Me!"ca causes of ab!o%"na pa"n
MIMIC ACUTE A#D"MEN
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MIMIC ACUTE A#D"MEN
MEDICAL C"NDITI"NSCo%%on
M-ocar!"a "nfarct"on
Pneu%on"a
Peur"s- Acute p-eonep&r"t"s
Irr"tabe boe s-n!ro%e
Tons""t"s' ot"t"s %e!"a "n c&"!ren
Unco%%on
D"abet"c etoac"!os"s
Acute porp&-r"a
A#D"MINAL PAIN
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A#D"MINAL PAIN
MEC+ANISMS
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A#D"MINAL PAIN
MEC+ANISMS :.Referre! pa"n a* Hro% t&e c&est (%-ocar!"a "nfarct"on' peur"s-*
b* Hro% t&e vertebra cou%n (nerve root
co%press"on' %uscuoseeta !"sor!ers* c* Hro% t&e #ona!s (tors"on of t&e testes*
=.M"sceaneous
a* Metabo"c !"sor!ers (urae%"a' !"abetes'porp&-r"a' &-percacae%"a' A!!"sonQs !"sease*
b* Ps-c&o#en"c !"sturbances ("rr"tabe boe
s-n!ro%e*
ACUTE A#D"MEN
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ACUTE A#D"MEN
Clinical picture Paro0-s% of severe ab!o%"na pa"n Per"tonea "rr"tat"on s"#ns (resp"rator- ab!o%en
e0curs"ons absent' S&c&et"n$@u%ber# s"#n *
S"#ns of !"sor!ere! per"stas"s / tone of GIT (nausea'
vo%"t"n#' pronounce! %eteor"s%' const"pat"on'passa#e of fatus' v"s"be per"stas"s > 9a&)s s"#n*
C"rcuator- coapse+ paor' s-ncope' co! seat'
rap"! / ea puse' o @P' p"nc&e! face (fac"es
,"ppocrat"ca*
Genera rap"!- pro#ress"n# s"#ns of "nfa%%at"on+
fever' neutrop&""c eucoc-tos"s' acceerate! ESR
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Locali-ation of a&doinal pain
Or#an E0terna oca"Fat"onon ab!o%"na a
Sto%ac& /!uo!enu%
Ep"#astr"u%' %"!"neor s"#&t- to t&e r"#&t
Transverse / s"#%o"!coon
Per"u%b""ca or r"#&t""ac fossa
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Locali-ation of a&doinal pain
Or#an E0terna oca"Fat"onon ab!o%"na a
R"#&t coon R"#&t oer 3ua!rant
Left coo% Left oer 3ua!rant
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Locali-ation of a&doinal pain
Or#an E0terna oca"Fat"onon ab!o%"na a
Rectos"#%o"! Suprapub"c
@a!!er Suprapub"c
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Locali-ation of a&doinal pain
Or#an E0terna oca"Fat"onon ab!o%"na a
Rectu% Loer bac' %"!"ne
Gaba!!er M"! ep"#astr"c'
ra!"at"n# to r"#&tupper 3ua!rant / tor"#&t scapuar area
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Locali-ation of a&doinal pain
Or#an E0terna oca"Fat"onon ab!o%"na a
Co%%on b"e !uct M"! ep"#astr"c'
ra!"at"n# to s&ou!eror retrosterna- tonec
Pancreas M"! ep"#astr"c'sprea!"n# atera- tobac "f poster"orper"toneu% "s"nvove!
ACUTE A#D"MEN
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ACUTE A#D"MEN
Clinical picture
,"stor-
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ACUTE A#D"MEN
Clinical picture
Ton#ue furre! "n %ost acute ab!o%"na
!"sease
Te%perature fever %ore co%%on "n
acute "nfa%%ator- con!"t"ons
ACUTE A#D"MEN
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ACUTE A#D"MEN
Clinical picture
E0a%"nat"on
a* S"#ns of per"ton"t"s
S"te of ten!erness
Guar!"n# > oca"Fe! or #enera"Fe! Reboun! ten!erness
b* S"#ns of obstruct"on
D"stens"on of ab!o%en !ue to #as Increase! #ut soun!s (borbor-#%"*
Absent #ut soun!s su##est per"ton"t"s
ACUTE A#D"MEN
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ACUTE A#D"MEN
In(esti$ations
Pev"c / recta e0a%"nat"on
Pev"c e0a%"nat"on for #-necoo#"ca !"sor!ers
(rupture! ectop"c pre#nanc-*
Recta e0a%"nat"on to !etect oca"Fe! ten!erness !* Ot&er observat"ons+
Ur"n"e ana-s"s for+
a* Gucose / Ketones (for !"abet"c etoac"!os"s*
b* 9@C > to e0cu!e acute p-eonep&r"t"s
c* P&orp&-r"ns $ to !etect porp&-r"a (rare
con!"t"on*
ACUTE A#D"MEN
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ACUTE A#D"MEN
In(esti$ations / treatent
,osp"ta"Fat"on
,our- ta"n# bo!- te%perature
Tota boo! counts
ECG
Ra!"o#rap&"c ab!o%en e0a%"nat"on (R$scop- /
R$#rap&-*
Sur#er-
ACUTE APPENDICITIS
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ACUTE APPENDICITIS
SYMPT"MS
ain begins as ague, central abdominal pain(around umblicus or epigastrium) & shifts to the
right iliac fossa within a few hours
'. "norexia (preceding the pain)
/. 0ausea & omiting (omiting is not so
fre1uent)
2. 3onstipation or diarrhoea: mostl! patients with
appendicitis deelop constipation for a few da!s
before the attack of the pain - a few patients
hae diarrhoea
ACUTE APPENDICITIS
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ACUTE APPENDICITIS
SI!NS
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ACUTE APPENDICITIS
Confirator% si$ns
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ACUTE APPENDICITIS
INVESTI!ATI"NS / TREATMENT
IN8ESTIGATIONS
@oo! CP+$ S&os eucoc-tos"s (on-
reac&"n# upper "%"ts $ not so %are!* TREATMENT
Appen!ecto%-
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!ASTRIC 7UICE ANALYSIS
Naso#astr"c tube $ "nto sto%ac&
Gastr"c contents asp"rate!+
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!ASTRIC 7UICE ANALYSIS
Deb"t$&our of ,C $ a%ount of free ,CL secrete!!ur"n# < &our
Hor%ua+ D ( ,C * A @ 2.2=1;
D ( ,C * $ !eb"t$&our of ,C A $ a%ount of #astr"c ?u"ce secrete! "n < &our
@ $ ac"!"t- of #astr"c ?u"ce "n t"trat"n# un"ts
2.2=1; $ %oecuar e"#&t of ,C
Nor%a @AO eve ran#es fro% ;2$
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!ASTRIC 7UICE E8AMINATI"N
Hast"n# sto%ac& ;2 %
,our- basa secret"on =2 $ b- #astr"c ?u"ce vou%e
(after parentera st"%uants or :; %"n. after test%ea* 5; %
,our- secret"on after st"%uat"on+
12 % ("nter%"ttent asp"rat"on*
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!ASTRIC 7UICE ANALYSIS
Pat&oo#"ca c&an#es+ Leve above nor%a @AO (;2$
&-perc&or&-!r"a Leve beo nor%a @AO (;2$
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INCREASED !ASTRIC SECRETI"N
5+YPERSECRETI"N6
,-persecret"on $ abnor%a "ncrease "n #astr"c?u"ce a%ount
Gastr"c &-perac"!"t- or &-perc&or&-!r"a $e0cess"ve #astr"c ac"!"t-
,-persecret"on+ #astr"c ?u"ce 4
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DIMINIS+ED !ASTRIC SECRETI"N
5+YP"SECRETI"N6
,-poc&or&-!r"a $ secretor- funct"on"%pa"r%ent "t& re!uce! free ,C
secret"on "n sto%ac&
Anac"!"t- or ac&or&-!r"a $ secretor-funct"on "%pa"r%ent "t& tota- absent
,CL
Gastr"c ac&-"a $ s"%utaneous absent ofpeps"n / ,C fro% #astr"c ?u"ce
DIMINIS+ED !ASTRIC SECRETI"N
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DIMINIS+ED !ASTRIC SECRETI"N
5+YP"SECRETI"N6
,C / peps"n %a- !"sappear as resut of
funct"ona !"sturbances (causes !"fferent"ate!
b- %eans of &"sta%"ne test*
Or#an"c sto%ac& es"ons $ ,C not secrete!even after &"sta%"ne "n?ect"ons
Hunct"ona !"sor!er $ free ,C "n #astr"c
content
DIMINIS+ED !ASTRIC SECRETI"N
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DIMINIS+ED !ASTRIC SECRETI"N
5+YP"SECRETI"N6
Absence of free ,C $ often "n !"seasesacco%pan"e! b- to0"cos"s / !eran#e%ent of
CNS funct"on caus"n# "n&"b"t"on of sto%ac&
secret"on
Or#an"c ac&-"a > "n atrop&"c processes "n
#astr"c #an!s !ue to "nfa%%ator- c&an#es'
%anutr"t"on' prote"n / v"ta%"n !ef"c"enc- "n
foo! Ma"n s"#ns+ #astr"c / "ntest"ne !-speps"a
! t i + t
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!astric p+0etr%
Nor%a p, "n esop&a#us $ neutra or s"#&t-aa"ne (5'2$5':*
Nor%a p, "n sto%ac&+
car!"a ver"tabe ac&or&-!r"a
! t i + t
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!astric p+0etr%
After "n#est"on of 2.; %# of Na,CO='sto%ac& p, "ncreases for about :2 %"n. /
t&en returns to "n"t"a eve
Decrease! esop&a#us p, $ #astro$esop&a#ea refu0
Neutra #astr"c p, $ ac&-"a
Increase of #astr"c p, after a!%"n"strat"onof Na,CO= 4=2 %"n. $ !uo!eno#astr"c
refu0 suspecte!
INADE9UATE DI!ESTI"N
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INADE9UATE DI!ESTI"N
SYNDR"ME
Upset cav"ta !"#est"on+ sto%ac& /"ntest"na !-speps"a
Upset par"eta !"#est"on
M"0e! for%
DYSPEPSIA $ ter% use! as coect"ve
!escr"pt"on for var"et- of
a"%entar- s-%pto%s
D i
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D%spepsia
SYMPTOMS INCLUDED IN TERM DYSPEPSIA
Upper ab!o%"na pa"n (%a- or not be reate! to
foo!*
Gastro$oesop&a#ea re#ur#"tat"on / &eartburn Anore0"a' nausea / vo%"t"n#
Ear- repet"on or sat"et- after %eas
A sense of ab!o%"na !"stens"on or boat"n#)(sense of ab!o%"na !"stens"on*
Hatuence (burp"n#' bec&"n#* / aerop&a#-
D%spepsia
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D%spepsia
Etiolo$%
Non$co%pensate! secretor- sto%ac&"nsuff"c"enc-
E0ocr"ne pancreas !-sfunct"on
Upset b"e secret"on D"sor!ere! c&-%e passa#e t&rou#& GIT+
stas"s' stenos"s' "ntest"na co%press"on'
"ntense per"stas"s > acceerate! passa#e
Intest"na "nfect"on / !-sbacter"os"s
A"%entar- !"sor!ers (overeat"n#' !"et r"c& "n
prote"n' fat' carbo&-!rate*
D%spepsia
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D%spepsia
Most coon causes
Sto%ac& !"sor!ers (atrop&"c #astr"t"s "t&ac&-"a or ac&or&-!r"a' sto%ac& cancer*
Intest"na !"sor!ers (enter"t"s*
D"sor!ers of re#uat"on of !"#est"ve process(so$cae! funct"ona !-speps"a $ "n!epress"on*
L"ver !"sor!ers (&epat"t"s' "ver c"rr&os"s*
D"sor!ers of pancreas (c&ron"c pancreat"t"s* En!o#enous (ure%"a' !"abet"c etoac"!os"s*
or e0o#enous (aco&o* "nto0"cat"ons
D%spepsia
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D%spepsia
Pat,o$enesis
Inco%pete brea!on of foo! part"ces
Act"ve propa#at"on of "ntest"na bacter"a fora
D-sbacter"os"s
Hunct"ona !-speps"a $ ps-c&oo#"ca factors
!astric D%spepsia
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!astric D%spepsia
Etiolo$% D-speps"a $ co%%on- assoc"ate! "t&
or#an"c !"seases of upper GIT+
Pept"c oesop&a#"t"s
Ac&or&-!r"a / ac&-"a
Pept"c ucer
Gastr"c carc"no%a
P-or"c stenos"s
Gastr"t"s
!astric D%spepsia
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!astric D%spepsia
Clinical picture Hee"n# of !"sco%fort Ep"#astr"u% pressure or !"stens"on after %eas Hre3uent eructat"on Re#ur#"tat"on (often "t& ac"! or fet"! o!or* Unpeasant taste "n %out& Nausea Poor appet"te
Ac&-ous !"arr&oea Meteor"s%
Gastr"c ?u"ce e0a%"nat"on >
ac&or&-!r"a or ac&-"a (peps"n / ,CL absence*
:unctional D%spepsia
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:unctional D%spepsia5Non ulcer d%spepsia6
Co%pa"nts of pers"stent !-speps"a "t&
e0cu!e! or#an"c causes $ non ucer
funct"ona !-speps"a
S-%pto%s of !"sturbance "n %otorfunct"on
of GIT !ue to ps-c&oo#"ca factors
Pat"ents $ usua- -oun# (beo 2 -ears *'
o%en %en :+ "n!"cat"on of presence ofacute "nfa%%ator- e0u!ates (ucerat"ve co"t"s' a%eb"cco"t"s / bac"ar- !-senter-*
H"0e! / sta"ne! s"!es of stoo for a%oebas / ot&erparas"tes
Stoo cuture $ for !"a#nos"s of bac"ar- !-senter- Su!an III sta"n of stoo $ screen"n# test for steatorr&ea
DIARR+"EA
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DIARR+"EA
Stoo e"#&t "ncrease 4 =22 # per !a-acco%pan"e! b- "ncrease! stoofre3uenc-
T-pes+Os%ot"c !"arr&eaSecretor- !"arr&ea Infa%%ator- !"arr&eaAb!o%"na %ot""t- !"arr&eaAnt"b"ot"c$assoc"ate! !"arr&ea
"sotic diarr,ea
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"sotic diarr,ea
Lar#e 3uant"t"es of non absorbe! &-perton"csubstances "n #ut u%en present >
fu"! enters boe !ue to os%ot"c pressure+
Pur#at"ve "ntae
Genera"Fe! %aabsorpt"on
Spec"f"c %aabsorpt"on (!"sacc&ar"!ase!ef"c"enc-*
Os%ot"c !"arr&ea stops &en pat"ent stops
eat"n# of %aabsorpt"ve substances
Secretor% diarr,ea
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Secretor% diarr,ea
Act"ve "ntest"na secret"on of fu"! /eectro-tes "t& !ecrease! absorpt"on+
Enteroto0"n (c&oera' E.co"*
@"e sats "n coon foo"n# "earesect"on
Hatt- ac"!s "n coon foo"n# "ea
resect"onHoo! !oes not affect !"arr&ea $ cont"nues!ur"n# fast"n#
Inflaator% diarr,ea
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Inflaator% diarr,ea
Da%a#e to "ntest"na %ucosa ces $oss of fu"! / boo!+
D-senter- (S&"#ea*
Ucerat"ve co"t"s
A&doinal otilit% diarr,ea
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A&doinal otilit% diarr,ea
Not true !"arr&ea $ vou%e /
e"#&t of stoo "s not "ncrease! "t&
"ncrease! fre3uenc- of
!efecat"on+
Irr"tabe boe s-n!ro%e
D"abet"c neuropat&-T&-roto0"cos"s
Anti&iotic0associated diarr,ea0
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Pseudoe&ranous colitis
After ta"n# ant"b"ot"cs (part"cuar-
a%p"c""n' "nco%-c"n / cep&aospor"n $
pro!uce pseu!o%e%branous co"t"s*S"#%o"!oscop- $ %ut"pe -eo pa3ues
/ "nfa%%at"on
Difference &et*een sall &o*el
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/ lar$e &o*el diarr,ea
Heatures S%a boe!"arr&ea
Lar#e boe!"arr&ea
Stoovou%e
Lar#e S%a
Stoo coour L"#&t Dar
Difference &et*een sall &o*el
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/ lar$e &o*el diarr,ea
Heatures S%a boe!"arr&ea
Lar#e boe!"arr&ea
Stoo s%e 8er- fou Hou
Stoo nature Soup- /#reas- Muc"nous /?e- "e
Difference &et*een sall &o*el
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/ lar$e &o*el diarr,ea
Heatures S%a boe!"arr&ea
Lar#e boe!"arr&ea
Stoo t-pe 9ater- Muco"!
@oo! "nstoo
Rare ("fpresent >
atere!*
Co%%on (usua-> fres& boo!' "f
fro% caecu% >%aroon cooure!
Difference &et*een sall &o*el
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/ lar$e &o*el diarr,ea
Heatures S%a boe!"arr&ea
Lar#e boe!"arr&ea
9@Cs "nstoo
Rare Co%%on
Ab!o%"napa"nocat"on
Per"u%b""care#"on' %"!ab!o%en(cra%p- /"nter%"ttent*
Loer ab!o%en(#r"pp"n# /cont"nuos*
Difference &et*een sall &o*el
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/ lar$e &o*el diarr,ea
Heatures S%a boe!"arr&ea
Lar#e boe!"arr&ea
Tenes%us Absent Present
Un!"#este!
%ater"a
Ma- be
seen
Inv"s"be
Difference &et*een sall &o*el
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/ lar$e &o*el diarr,ea
Heatures S%a boe!"arr&ea
Lar#e boe!"arr&ea
Steatorr&ea Ma- beseen
Not seen
Hre3uenc- Less More
A&noral stool 0 o&;ecti(e e(idencef l i di
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of colonic disease
Stoo e0a%"nat"on b- p&-s"c"an $ as soon as poss"be after!efecat"on for presence of v"s"be boo! on surface or "t&"nt&e spec"%en' test for occut boo!
M"croscop"c e0a%"nat"on of fres& stoo $ !"a#nos"s ofparas"t"c !"seases (a%eb"c co"t"s $ %ot"e trop&oFo"ts "n
fres&' ar% stoo suspens"on* Stoo suspens"on sta"ne! "t& a !rop of %et&-ene bue for
po-%orp&onucear euoc-tes > "n!"cat"on of presence ofacute "nfa%%ator- e0u!ates (ucerat"ve co"t"s' a%eb"cco"t"s / bac"ar- !-senter-*
H"0e! / sta"ne! s"!es of stoo for a%oebas / ot&erparas"tes
Stoo cuture $ for !"a#nos"s of bac"ar- !-senter-
Su!an III sta"n of stoo $ screen"n# test for steatorr&ea
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Management
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g
7estoration of blood olume
- restoration of blood olume can be best
achieed b! transfusion of whole blood
- before blood arrangement, restored bloodolume with 8.9 normal saline and plasma
expender ( haemacel )
- the rate of blood transfusion must bemonitored carefull! to aoid oer transfusion
and conse1uent heart failure
Occult GI Bleeding
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Occult GI Bleeding
5s the lost of small amount of blood into tractwhich is present in stool but cannot be seen
( no hematochezia or melena )
it is t!picall! detected in of the ' settings :a) positie feacal occult blood test
b) the presence of iron deficienc! anemia in an
adult
Etiology
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"ll causes of upper and lower ;5 bleeding ma!
also cause occult bleeding, following are thecommon cases:
. 6umors : benign or malignant
- tumor of an! site of ;56, especiall! colon cancer
'. eptic ulcer and esophagitis
/. 0
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. 7ectal examination, anoscop! andsigmoidoscop! are performed to look for
eidence of anorectal disease, inflammator!
bowel disease or infectious colitis
- if source is identified, no further inestigations
are needed immediatel! unless bleeding persist
or is recurrent
'. $xclude an upper tract source : passnasogastric tube in patients with significant
bleeding to look for e idence of pper ;5 so rce