Manifestations of gastrointestinal diseases copy

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  • 1. Manifestations of Gastrointestinal Diseases
    • Celso M. Fidel MD,FPSGS,FPCS
  • Diplomate Philippine Board of Surgery

2. What are These Manifestations?

  • 1. PAIN
  • 2. FEVER
  • 3. ANOREXIA
  • 4. HEARTBURN and DYSPEPSIA
  • 5. DYSPHAGIA
  • 6. NAUSEA and VOMITING
  • 7. ABDOMINAL DISTENTION,
  • ERUCTATION and FLATULENCE
  • 8. CONSTIPATION
  • 9. DIARRHEA

3. What are These Manifestations?

  • 10. ILEUS
  • 11. INTESTINAL OBSTRUCTION
  • a. Partial Obstruction and Pseudo-obstruction
  • b. Mechanical Obstruction
  • c. Closed Loop Obstruction
  • d. Colon Obstruction
  • 12. GASTROINTESTINAL BLEEDING
  • a. Upper GI Bleeding
  • b. Lower GI Bleeding
  • 13. JAUNDICE

4. 5. IPain

  • Most common symptom of GIT disease
  • Three kinds have been described in gen.
  • 1. Superficial or Cutaneous pain
  • 2. Deep pain from:
  • Muscles
  • Tendons
  • Joints
  • Fascia
  • 3. Visceral pain

6. IPain

  • Two Types of Pain
  • 1. Somatic Pain2. Visceral Pain
  • Pathway:A-delta fibers Autonomic C-type fibers
  • Receptor:Parietal, MuscleVisceral
  • and Skin
  • SpecificWell localizedPoorly localized
  • DescriptionSharpCramping, Gnawing
  • Stimulus:Inflammation,Distention, Traction
  • Pressure

7. Pain

  • Un-referred Visceral Pain
  • ANS innervations:
  • bilateral hence pain is midline except:
  • Kidneys
  • Ureters
  • Cecum
  • Ascending colon
  • Descending colon
  • Sigmoid colon

8. Pain

  • Un-referred Visceral Pain
  • Midline location is the result of embryologic development ofGut
  • Epigastric - Foregut:
  • Oropharynx
  • 2 ndportion of duodenum
  • Liver
  • Spleen
  • Pancreas

9. Pain

  • Un-referred Visceral Pain
  • Periumbilical- Midgut:
  • Distal duodenum
  • Jejunum
  • Ileum
  • Appendix
  • Ascending colon
  • Proximal transverse colon
  • Hypogastric- Remainder of Hindgut= Colon
  • down toc loaca

10. Pain

  • REFERRED PAIN
  • Result of afferent neurons that innervate two entirely separate anatomically distinctstructures that have acommon embryologic
  • origin

11. Pain

  • REFERRED PAIN
  • 4 th Cervical Nerve Route
  • 1. Parietal peritoneum of the
  • diaphragm
  • 2. Area around the shoulder
  • 3. Supraclavicular hollow
  • e.g.Kehr sign = Pain underneath the diaphragm felt at the tip of theshoulder

12. Pain

  • REFERRED PAIN
  • Thoracic Afferents T6-T8
  • Innervates :
  • 1. Right sub-scapular area
  • 2. Biliary tree
  • 3. Liver
  • 4. Peri-pancreatic area

13. Pain

  • REFERRED PAIN
  • 10 thThoracic Nerve Route
  • Irritation to the kidney or ureter
  • e.g. In male= Flank and genital
  • pain classically testicular pain
  • In females this is referred to the
  • labia

14. Acute Abdominal Pain

  • Clinical Manifestations
  • Sudden Onset =more likely surgical
  • Gradual Onset= inflammatory process
  • or slower progressive obstruction
  • Nausea and Vomiting 6-12 hours after
  • onset of pain=Obstruction lower GIT

15. Acute Abdominal Pain

  • Clinical Manifestations
  • ForegutandMidgutinflammation
  • oftenfollowed by:
  • Anorexia
  • Nausea
  • vomiting
  • Sensory afferents carried by Vagal fibers

16. Acute Abdominal Pain

  • Physical Examination
  • Inspection
  • Scaphoid = Normal
  • Distention= Abnormal
  • Thin Individuals= bowel loops seen

17. Acute Abdominal Pain

  • Auscultation
  • Absent =No bowel sound in a minute
  • 1. Ileus
  • 2. Hypokalemia
  • 3. Peritonitis
  • 4. Hypomagnesemia
  • 5. Mesenteric thrombosis
  • 6. Narcotic Overdose

18. Acute Abdominal Pain

  • Auscultation
  • Hypoactive
  • 1. Hypokalemia
  • 2. Inflammation
  • 3. Ischemic bowel disease

19. Acute Abdominal Pain

  • Auscultation
  • Hyperactive
  • 1. Early small bowel obstruction
  • 2. Diverticulitis
  • Percussion
  • Palpation

20. Acute Abdominal Pain

  • Laboratory Evaluation
  • CBC
  • Urinalysis
  • Blood Chemistrye.g. Amylase; Liver
  • function test
  • Pregnancy Test
  • ECG

21. Acute Abdominal Pain

  • Radiologic Examination
  • 1. Pneumoperitoneum
  • 2. Calculi
  • 3. Ileus
  • 4. Air fluid level
  • 5. Aerobilia
  • 6. Fat lines

22. Acute Abdominal Pain

  • Ultrasound
  • 1. Suspected Pancreatic
  • 2. Hepatobiliary disease
  • 3. Phlegmon
  • 4. Abscess
  • 5.Pseudocyst
  • 6. Gynecologic Problem that mimics GIT
  • disease

23. Acute Abdominal Pain

  • Ultrasound
  • (F.A.S.T.) detecting Hemoperitoneum
  • in Blunt Trauma
  • 1. Sensitivity of 93.4%
  • 2. Specificity of 98.7%
  • 3. Accuracy of 97.5%

24. Acute Abdominal Pain

  • Surgical Decision Making
  • 1. Usually made by History
  • 2. Physical Examination is confirmatory
  • 3. Laboratory tests are focused on the
  • suspected diagnosis

25. Acute Abdominal Pain

  • Nature of Surgical Decision Making in
  • Acute Abdomen does not require
  • specific diagnosis, but
  • 1. Plan of action
  • 2. Indication for the operation
  • 3. Timing and Approach

26. Intermittent and Recurrent Abdominal Pain

  • 1. Various Hematologic disorders produce
  • abdominal pain
  • 2. Clinical Manifestations relate to the
  • occurrence of crisis; anemia; jaundice;
  • splenomegaly; and cholelithiasis
  • 3. Due to disturbed gastrointestinal motility
  • or alternating areas of spasm and
  • dilatation

27. Chronic Abdominal Pain

  • If persistent-- is a clear pathophysiologic
  • abnormality such as:
  • 1. Chronic pancreatitis
  • 2. Pancreatic Malignancy
  • 3. Colonic Malignancy
  • May arise from the abdominal wall
  • 1. Iatrogenic peripheral nerve injuries
  • 2. Hernias
  • 3. Myofascial Pain Syndrome

28. Intractable Abdominal Pain

  • 1. Challenging and sometimes a frustrating
  • problem
  • 2. Opiate Analgesics, if given in sufficient
  • dosage, usually can control abdominal
  • pain, however risk of addiction isalways
  • there undermining patients ability to
  • function effectively
  • 3.In Properly selected patients,interruption
  • of pain pathway (Splanchnicectomy) is
  • suggested

29. II FEVER

  • Not dangerous unless it is unusually high
  • Often a postoperative event often:
  • 1. A Thermostat reset
  • 2. Response to intraoperative body cooling
  • 3. Result of Normal Cytokine Activation

30. II FEVER

  • Indication of Illness such as:
  • 1. Infection
  • 2. Inflammation
  • 3. Autoimmune Disease
  • 4. Neoplasia
  • If persistent, indicative of infectiouscomplication

31. II FEVER

  • Pathophysiology
  • Inflammatory Response activat