Penyakit dan kelainan sistem gastroenterologi dan pankreatobilier(Diseases and Abnormalities in the Gastroenterological and Pancreatobiliary System)
Marcellus Simadibrata K MD PhD SpPD KGEH FACG FINASIM
Department of Medical Education Faculty of Medicine University of IndonesiaDivision Gastroenterology Department of Internal Medicine Faculty of Medicine University of Indonesia
Lecture Module Gastrointestinal May 2013
Introduction
Gastrointestinal Diseases and Abnormalities: Upper and Lower border: Treitz ligament
Diseases in upper GI tract: Syndrome of dyspepsia, Gastroesophageal Reflux Disease(GERD), dysphagia, peptic ulcer, upper gastrointestinal bleeding(Hematemesis-Melena), polyp and cancer of the gaster/duodenum, cholangitis, bile duct Stone, pancreatitis.
Diseases in lower GI tract: diarrhea, irritable bowel syndrome, collitis infective-non Infective, Inflammatory Bowel Disease, polyp and cancer of the colon, hemoroid
Buku ajar Ilmu Penyakit Dalam. PIP Penyakit dalam jilid 1. 2005
Syndrome of Dyspepsia
Definition : persistent or recurrent upper abdominal pain or discomfort characterized by postprandial fullness, early satiety, nausea, and bloating.
Classification: Functional and organic , or ulcer and non ulcer(NUD)
Functional: dysmotility like, ulcer like, non-specific, (reflux like). Functional: no organic diseases.
Organic(with x-ray or endoscopy): peptic ulcer, cancer, severe gastritis-duodenitis.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
PATHOGENESIS of Gastric mucosal Damage
Figure1. The Balance between aggressive and defensive factors
Aggressive factors Defensive factors Gastric acid Mucosal blood flow Pepsin Epithelial cell surface Bile reflux Prostaglandin Nicotine Phospholipid/surfactan NSAID Mucus Corticosteroid Bicarbonate Helicobacter pylori Motility Free radicals Mucosal impermeability to Stress H+ ion Intracellular pH regulation Growth factor
cited from Daldiyono & Shiessel R et.al.
Clinical features in syndrome dyspepsia NUD: 1. ulcerlike: dominant epigastric pain, relieved by
antacids or food 2. dysmotility like: epigastric discomfort aggravated
by food or associated with early satiety, fullness, nausea, retching, vomiting, or bloating.
3. nonspecific: symptoms does not fit the other categories
Ulcer: the same with NUD
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Findings and diagnostic findings in syndrome dyspepsia
routine: blood, stool, amylase-lypase , liver function test . upper gastrointestinal endoscopy: if age > 45 years or
NSAID consumption or alarm symptoms: weight loss,hemorrhage, dysphagia, vomiting, jaundice. Biopsy for histopathological or helicobacter pylori.
Double contrast upper gastrointestinal barium radiography
Gastric scintigraphy: gastric gastroparesis/motility Helicobacter pylori serology examination. Ultrasound/CT-scan: to exclude gallbladder/biliary
stone/malignancies, pancreatitis.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Management of Syndrome Dyspepsia:
Avoid/stop -decrease the aggravating/agresive factors, increase the defensive factors.
Young patients < 45 years, no NSAID consumer nor alarm symptoms : empiric therapy 2-4 weeks: Ulcer like: antacids or h2 receptor antagonist or proton pump inhibitor. Dysmotility like: prokinetic or h2 receptor antagonist. Nonspecific: antifatulent antacids, simethicone, antianxiety-depression.
Peptic ulcer: H2RA or PPI with/without cytoprotector Upper GI malignancies: operation.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
DEFINITION: a pathologic consequences of the effortless movement of gastric contents to the esophagus, including symptoms or signs referable to the esophagus, pharynx, larynx, and respiratory tract.
CLINICAL FEATURES: Heartburn, substernal chest discomfort, regurgitation bitter or acid-tasting liquid, water brash or hypersalivary, solid dysphagia, odynophagia, oropharynx damage(sorethroat, erache, gingivitis, poor dentition, and globus), reflux damage of the larynx and respiratory tract (hoarseness, wheezing, bronchitis, asthma, pneumonia).
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Pathophysiology of GERD
Spectrum Of Endoscopic Findings with GERD
Normal esophagus Grade 3 esophagitis
Grade 4 esophagitis Barrett’s esophagus
MANAGEMENT of GERD
Lifestyle modification: Head elevation, stop smoking/alcohol, reduce meal size and intake of fat/carminative/chocolate/coffee, carbonated beverages, tomato juice, citrus products, stop medications reducing LES pressure (anticholinergics, theophylline etc.)
Medication therapy: - Acid suppressive drugs: 1. Proton pump inhibitor(PPI)( omeprazole, lansoprazole, rabeprazole, pantoprazole, esomeprazole): drug of choice 2. H2 receptor antagonists(cimetidine, ranitidine, famotidine, nizatidine): mild-moderate 3. Liquid Antacids: good for mild - Prokinetics agents: metoclopramide, domperidone, cisapride Surgical treatment. Endoscopic fundoplication.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
PEPTIC ULCER DISEASE(PUD)-1 DEFINITION: PUD Mucosal break gaster and duodenum,
diameter more than 0,5 cm. Refractory ulcer duodenal ulcer 8 weeks therapy ineffective or gastric ulcer lack response to 12 weeks treatment.
PATHOGENESIS: Imbalance, aggressive factors >>> defensive factors(see dyspepsia).
Simadibrata M. Penatalaksanaan tukak peptik MKI 2007Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
CLINICAL FEATURES of PUD
Abdominal pain 94%: epigastric in location, does not radiate, occurs 2-3 hours postprandially, and relieved by food or antacids. Some time awakens the patient between midnight and 3 AM.
Some patients have no symptoms Complications: hemorrhage(melena)(15%),
perforation(7%), penetration, and obstruction(2%).
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
FINDINGS ON DIAGNOSTIC TESTING of PUD routine blood(Hb, leukocyte) & stool(occult blood test) Upper gastrointestinal barium radiography: gastric &
duodenal ulcer Upper gastrointestinal endoscopy: gastric & duodenal
ulcer, biopsy for histopathological examination: benign/malignant disease, Helicobacter pylori infection
Helicobacter pylori testing: serology, culture/CLO test/histopathology examination from upper GI endoscopy examination, C-Urea Breath test, Stool’s H.pylori antigen
Serum gastrin and gastric acid secretion testing: hypergastrinemia in gastrinoma
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
MANAGEMENT of PUD-1 Non pharmacological management: - stomach diet, - avoid/stop aggressive factors: stress etc. Pharmacological management: - H2 receptor antagonist. - Proton pump inhibitors. - Cytoprotective Agents: Sucralfate, Misoprostol, Bismuth subsalicylate, Tephrenone and Rebamipide
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Helicobacter pylori Eradication(KSHPI)
Tripple therapy(1 or 2 weeks): 1. PPI+Amoksisilin+Klaritromisin
2. PPI+Metronidazol+Klaritromisin 3. PPI+Metronidazol+Tetrasiklin (alergy to chlarithromisin) Quadruppel therapy(1 or 2 weeks): 1. If
fail of therapy combination 3 drugs: Bismuth+PPI+Amoksisilin+Klaritromisin Bismuth+PPI+Metronidazol+Klaritromisin 2. Hight resistency areas: PPI+Bismuth+Tetrasiklin+Metronidazol
PPI 2 x/d; Omeprazol/Esomeprazol 20 mg, Lansoprazol 30 mg, Pantoprazol 40 mg, Rabeprazol 10 mg. Amoksisilin: 2 x 1000 mg/d, Klaritromisin 2 x 500 mg/d, Metronidazol 3
x 500 mg/d, Tetrasiklin 4 x 250 mg/d, Bismuth 4 x 120 mg/d.
KSHPI, Konsensus infeksi Helicobacter pylori di Indonesia 2003
DYSPHAGIA DEFINITION: - Dysphagia sensation of food being hindered in
its passage from the mouth to the stomach. - Odynophagia pain on swallowing. - Globus sensation perception of a lump,
tightness, or fullness in the throat that is temporariloy relieved by swallowing.
CATEGORY: Dysphagia divided into: 1. Illnesses involving oral preparation, oral transfer, or pharyngeal phases of swallowing
2. conditions involving dysfunction of the
esophageal phase
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Table 1. Causes of dysphagia Oropharyngeal dysphagia Neuromuscular diseases Cerebrovascular accident Parkinson’s disease Wilson’s disease Amyotrophic lateral sclerosis Brain stem tumors Bulbar poliomyelitis Peripheral neuropathy Myasthenia gravis Muscular dystrophies Polymyositis Metabolic myopathy Amyloidosis Systemic lupus erythemathosus Local mechanical lesions Inflammation(pharyngitis, abscess, tuberculosis, radiation, syphilis) Neoplasm Congenital webs Plummer-vinson syndrome Extrinsic compression(thyromegaly, cervical spine hyperostosis, adenopathy) Oropharyngealk resection Upper esophageal sphincter(UES) disorders Hypertensive UES Hypotensive UES Abnormal UES relaxation(cricopharyngeal achalasia, central nervous system, lymphoma, Oculopharyngeal muscular dystrophy, cricopharyngeal bar, Zenker’s diverticuum, familial Dysautonomia)Esophageal dysphagia Motility disorders Achalasia Scleroderma Diffuse esophageal spasm Nutcracker esophagus Hypertensive lower esophageal sphincter Nonspecific esophageal dysmotility Other rheumatologic conditions Chagas’ disease Intrinsic mechanical lesions Benign stricture(peptic, lye, radiation) Schatzki’s ring Carcinoma Esophageal webs Esophageal diverticula Benign tumors Foreign bodies Extrinsic mechanical lesions Vascular compression Mediastinal abnormalities Cervical osteoarthritis
DIAGNOSIS of Dysphagia
History: distinguish oropharyngeal / esophageal in location and if it is structural or neuromuscular in origin. Etc.
Physical examination: The head and neck sensory and motor function of the cranial nerves, masses, adenopathy, or spinal deformity. Examine systemic disease.
Additional testing: Barium swallow radiography, Upper endoscopy and biopsy, UES manometry.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Management of Dysphagia
The management depend on the cause. Neuromuscular disease—myotomy(surgical) Benign strictures—dilatation by bougienage Early malignancies –surgically resected Unresectable malignancies – dilatation, cautery, laser or stenting Achalasia—medications(calcium channel antagonists), botulinum
toxin injection into the LES, by endoscopic dilation, and by surgical myotomy.
Other primary esophageal dysmotilities respond to nitrates, calcium channel antagonist, surgical myotomy.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
ACHALASIA-1
The most easily recognized & best-defined motor disorder of the esophagus
Incidence 1 per 100.000 population per year in US. Classification: Primary & Secondary. Neuropathology: LES failure to relax completely &
aperistalsis smooth muscle esophagus damage innervation loss of ganglion cells within myenteric(Auerbach) plexus, degeneration vagus nerve & degeneration dorsal motor nucleus vagus.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
ACHALASIA-2
Clinical manifestation: dysphagia(100% solid & half liquid), regurgitation, chest pain, weight loss& aspiration pneumonia.
Esophagogram: esophageal dilatation with distal stenosis bird beak(paruh burung)/rat tail(ekor tikus).
Esophagoscopy: esophageal dilatation /atony with food residue/saliva.
Treatment: Dilatation(bougie, pneumatic-balloon), Botulinum toxin injection, Operation.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
UPPER GASTROINTESTINAL
BLEEDING(HEMATEMESIS-MELENA)
DEFINITION: Upper gastrointestinal bleeding/ hematemesis melena refers to bleeding source from the upper gi tract. The blood in stool – tarry stools, the blood vomiting—black tarry vomiting
EPIDEMIOLOGY: - The frequent cause of upper gi bleeding in Indonesia is rupture of esophageal varices. - The frequent cause of upper gi bleeding in Europe is peptic ulcer.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Bad Predictor in upper gastrointestinal bleeding Age > 60 years Other comorbid Hypotension or shock Coagulopathy Bleeding onset in hospital Transfusion requirement > 6 unit Fresh bleeding from stomach Recurrens bleeding from the same lesion
Triadapafilopoulos G. Aliment Pharmacol Ther 2005;22(suppl.3): 53-8
WORKUP/DIAGNOSIS of Hematemesis Melena Resuscitation History Physical examination Upper gi endoscoopy Scintigraphy and angiography: the rate of blood loss
must exceed 0.5 ml per minute. Other radiographic studies: for aortoenteric fistula
abdominal computed tomographic or magnetic resonance imaging studies
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
MANAGEMENT of Hematemesis Melena
Blood Transfusion Medications: PUD/gastritis: H2RA, or PPI; varices or portal
gastropathy: vasopressin / terlipressin / somatostatin or octreotide . Angiodysplasia: intravenous or oral estrogens with or without progesterone.
Therapeutic endoscopy: thermal and nonthermal methods. Emergency upper endoscopy ; esophageal banding or
sclerotherapy. Mechanical compression: ballon tamponade/Senstaken-
Blakemore tube or Linton-nachlas , then followed by sclerotherapy or ligation.
Therapeutic angiography Surgery:if endoscopy fails
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
LOWER GASTROINTESTINAL BLEEDING DEFINITION: Lower gastrointestinal
bleeding refers to bleeding source from the lower gi tract. The blood in stool – red fresh bloody stools.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
ETIOLOGY/CAUSES/DIFFERENTIAL DIAGNOSIS LOWER GI BlEEDING
Diverticulosis Angiodysplasias Hemorrhoids Anal fissures Neoplasms Inflammatory bowel disease Ischemic colitis Infectious colitis Radiation induced colitis Meckel’s diverticulum Intussusception Aortoenteric fistula Solitary rectal ulcera NSAID-induced cecal ulcers
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
DIAGNOSIS/WORKUP
Resuscitation: correction of volume deficits & stabilization of hemodynamic variables. If suspected upper gi bleeding ngt, Laboratory studies
History & Physical examination: GI diseases such as IBD, malignancy(weight loss, anorexia, lymphadenopathy, or palpable masses) etc
Additional testing: Endoscopy, Scintigraphy & angiography, Other radiologic studies(Barium enema).
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
MANAGEMENT LOWER GI BLEEDING-1 Medications. Therapeutic endoscopy. Therapeutic angiography. Surgery
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
ACUTE ABDOMEN
DEFINITION: Acute abdomen refers to any acute intra & extra abdominal disease processes. Many cases require urgent surgical management, although some can be managed nonsurgically.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
ETIOLOGY/CAUSES/DIFFERENTIAL DIAGNOSIS OF ACUTE ABDOMEN
Gastrointestinal Appendisitis Perforated peptic ulcer Intestinal ischemia Diverticulitis Inflammatory bowel disease Meckel’s diverticulitis Pancreaticobiliary tract, liver, spleen Acute pancreatitis Calculous cholecystitis Acalculous cholecystitis Acute cholangitis Hepatic abscess Ruptured hepatic tumor Splenic rupture Urinary tract Renal/ureteral stone Gynecologic Ectopic pregnancy Tuboovarian abscess Ovarian torsion Uterine rupture Ruptured ovarian cyst or follicle Retroperitoneum Abdominal aortic aneurysm Supradiaphragmatic Pneumothorax Pulmonary embolus Acute pericarditis Empyema
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
WORKUP/DIAGNOSIS ACUTE ABDOMEN-1 History: Acute appendicitis: periumbilical pain, low-grade fever, anorexia
with/without vomiting followed by movement of the pain into the right lower quadrant McBurney’s point.
Constipation: obstructive conditions, inflammatory disorders produce ileus.
Watery diarrhea: gastroenteritis, Bloody diarrhea: infectious colitis, inflammatory bowel disease,
mesenterial ischemia. Jaundice: hepatic and pancreaticobiliary disease, sepsis. Urinary abnormality : urologic disease. Physical examination: Appendicitis acute: local peritonitis at McBurney’s point, psoas
sign(+). Perforation: general/local peritonitis, disappear of liver percussion
dullness. Bruits mesenteric thrombosis. Ectopic pregnancyunilateral adnexal mass with blue cervical
discoloration.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
WORKUP/DIAGNOSIS ACUTE ABDOMEN-2 Initial studies: Blood testing: anemia, leukocytes, or leukopenia, serum
electrolytes, blood urea nitrogen, and creatinine, pregnancy test,
Peritonitis abdominal radiographs(3 positions abdominal xray)
Gas in the biliary tree – fistula or cholangitis. Ileus diffusely dilated loops of the small intestine & colon.
Free subdiaphragmatic air 75% patients with ulcer perforation.
Decision to operate immediately Imaging studies: CT-scan, ERCP/MRCP
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
MANAGEMENT OF ACUTE ABDOMEN
Urgent surgery Conservative management
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
DIARRHEA
DEFINITION: Stool soft or watery with a daily stool weight of > 200 g(250g). Frequency more than 3 times/day
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
CAUSES/DIFFERENTIAL DIAGNOSIS OF DIARRHEA High output osmotic Nonabsorbed solutes Saline and phosphate laxatives Sorbitol, fructose, lactulose Disaccharidase deficiency Lactase deficiency Isomaltase-sucrase deficiency Trehalase deficiency Small intestinal mucosal disease Celiac spure Tropical sprue Viral gastroenteritis Whipple’s disease Amyloidosis Intestinal ischemia Lymphoma Giardiasis Pancreatic insuffciency Chronic pancreatitis Pancreatic carcinoma Cystic fibrosis Reduced intestinal surface area Small intestinal resection Enteric fistulae Jejunoileal bypass Bile salt malabsorption Bacterial overgrowth Ileal resection Crohn’s disease Defective transport Congenital chloridorrhea High-output secretory Laxatives Bisacodyl Phenolphthalein Ricinoleic acid Dioctyl sodium sulfosuccinate Bacterial toxins Vibrio cholerae Toxigenic Eschericia coli Clostridium perfringens Hormonally induced Vasoactive intestinal polypeptide Serotonin Calcitonin Glucagon Gastrin Substance P Prostaglandins
Defective neural control Diabetic diarrhea Bile acid diarrhea Ileal resection Crohn’s disease Bacterial overgrowth Post cholecystectomy Mucosal inflammation Collagenous colitis Lymphocytic c olitis Villous adenoma High output injury Inflammatory bowel disease Crohn’s disease Ulcerative colitis Acute infections Viruses(rotavirus, Norwalk agent) Parasites(Giardia, Cryptosporidium, Cyclospora) E.coli Shigella Salmonella Campylobacter Yersinia enterocolitica Entamoeba histolytica(amebiasis) Chronic infections E.histolytica(amebiasis) Clostridium difficile Ischemia Atherosclerosis Vasculitis Normal output Motility disorders Irritable bowel syndrome Endocrinopathies Hyperthyroidism Proctitis Ulcerative proctitis Infectious proctitis Fecal incontinence Surgical and obstetrical trauma Hemorrhoids Anal fissures Perianal fistulae Anal neuropathy(diabetes
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
CLASSIFICATION
Time: acute less than 15 days chronic more than 15 days
Organic diseases: Organic and functional Infective/infectious causes: Infective/infectious and
non-infective/infectious Stool: soft, watery, bloody or steatorrhea, bloody ,
nonsteatorrhea nonbloody Pathomechanism: osmotic, secretory, increased
motility, mucosal inflammation,
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
DIAGNOSIS OF DIARRHEA-1 - History: Duration of diarrhea, recent travel, sexual practices, ingestion
of well water and poorly cooked food and shellfish, and exposure to high-risk persons in day care centers, hospitals, mental institutions, and nursing homes.
The characteristics of the diarrhea causative organism. Watery diarrhea+nausea, little paintoxin producing bacteria. Invasive bacteria pain, bloody diarrhea. Viruses watery diarrhea, pain significant, fever, mild-
moderate vomiting. Homosexual men, prostitutes, iv drug abusers diarrhea
through oral-fecal transfer. Antibiotic associated colitis recent antibiotic use. Recent medications: antacids containing magnesium,
antirrhytmias, antihypertensives, diuretics, central nervous system drugs, antiarthritis, cholesterol lowereing medications and theophylline.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
DIAGNOSIS OF DIARRHEA-2 – Physical Examination Abdominal tumor/mass, dehydration, fever etc. Hypotension, decreased skin turgor, dry mucous membranes
dehydration need intravenous hydration. Emaciation, cheilosis and glossitis severe malabsorption. Dermatitis herpetiformis celiac sprue, Pyoderma gangrenosusm inflammatory bowel disease, Sclerodactily scleroderma. Arthritis inflammatory bowel disease or Whipple’s disease. Resting tachycardia hyperthyroidism, pulmonic stenosis and
tricuspid regurgitation carcinoid syndrome. Peripheral or autonomic neuropathy visceral neuropathy in
diabetes and intestinal pseudo-obstruction. Neuropsychiatric findings Whipples disease. Abdominal mass malignancy, Crohn’s disease, diverticulitis. Localized abdominal tenderness inflammatory condition. A digital rectal examination perianal disease with Crohn’s disease,
reduced sphincter tone incontinence. Occult or gross fecal blood infectious, inflammatory and neoplastic
conditions.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
DIAGNOSIS OF DIARRHEA-3 - Acute diarrhea
Routine stool examination. Complicated and prolonged infection, unresponsive to
supportive care routinestool culture for Salmoneella, shigella, or Campylobacter organisms.
Special culture techniques Yersinia, Plesiomonas organisms and enterohemorrhagic E.coli.
Stool samples for parasitic disease—ova & parasites: Giardia, Cryptosporidium, E.histolytica or Strongyloidesorganisms.
Recent antibiotic use –Stool C.difficile culture and toxin determination.
20-40% acute infectious diarrhea remain undiagnosed despite laboratory evaluation.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
DIAGNOSIS OF DIARRHEA-4- Chronic diarrhea
Stool examination for leukocytes, fat (Sudan stain) for fat malabsorption, parasites and stool culture.
Antibiotic use culture C.difficile. Serum electrolyte Erythrocyte sedimentation rate systemic inflammatory
disease. Serum albumin and globulin reduced malabsorption,
malnutrition, or protein losing enteropathy. Additional blood testsfor malnutrition: carotene, iron,
folate, vitamin B12, cholesterol, alkaline phosphatase and prothrombin time.
Flexibel sigmoidoscopy exclude proctitis, pseudomembranes and melanosis coli due to laxative abuse.
Biopsy for normal appearance microscopic and collagenous colitis or irritable bowel syndrome.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
MANAGEMENT OF DIARRHEA
Intravenous resuscitation Agents for mild diarrhea: antidiarrheal, bismuth subsalicylate,
diphenoxylate, codeine. Antibiotics for acute infectious diarrhea Therapy for osmotic diarrhea: carbohydrate malabsorption
lactase deficiency or fructose or sorbitol intolerance dietary modification, lactase supplements
Therapy of secretory diarrhea somatostatin analog(octreotide), parenteral calcitonin, indomethacine.
Therapy for inflammatory diarrhea anti-inflammatory drugs(aminosalicylate and corticosteroid. Refractory cases azathioprine, 6mercaptourine, methotrexate.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Polyp and Cancer of the gaster/duodenum Definition: tumor of the gaster/duodenum,
benign and malignant(cancer) Management: polypectomy per endoscopic or
operation
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Cholangitis
Definition: Infection of the common bile duct due to obstruction like biliary stone or cholangiocarcinoma or papillary tumor.
Management: - Antibiotic - ERCP diagnostic and therapetic(sphincterotomy + stone extraction or stenting) - Operative: laparoscopic cholecystectomy & stone extraction or laparotomy biliodigestive procedure
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Bile duct Stone
Definition: Stone of the common bile duct. Management:
ERCP or operation
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Pancreatitis
Definition: Inflammation or infection of the pancreas
Classification: Acute and Chronic Management:
1. Conservative: Fasting, total parenteral nutrition, antibiotics, octreotide/somatostatin, anti TNF).
2. Surgery
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Acute pancreatitis with pancreatic enlargement& Peripancreatic edema & pseudocysts
Diagnosis of Acute Pancreatitis
• Clinical Features: abdominal pain, vomiting• Elevation of plasma amylase - lipase recommendation grade A 3 or 4 x normal (must not always rely on this value)• Plain radiograph• Abdominal Ultrasonography: pancreatic swelling(25-50% patients), CBD/gall bladder stones, dilatation of the CBD• Abdominal CT-scan(recommendation grade C)• Abdominal Magnetic Resonance Imaging(MRI)• CBD stones: ERCP & MRCP
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Severity of Acute Severity of Acute pancreatitispancreatitis Mild ( Edema type ): fat necrosis of the
pancreatic superficial & interstitial edema Severe( Hemorrhagic-Necrotic type): diffuse
fat necrosis of pancreatic superficial and parenchymal. Necrotic and bleeding of the pancreatic parenchymal.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Etiologic factor & Pathogenesis in Acute PancreatitisEtiologic factor & Pathogenesis in Acute PancreatitisEtiologic factor(Biliary, alcoholism, unknown etc)
Initial process(bile reflux, duodenal refux etc)
Initial damage of the pancreas(edema, vascular injury, acinar pancreatic duct rupture) Digestive enzyme activation Trypsin
Phospholipase A Elastase Lypase Chymotrypsin Kallikrein
Autodigestive
Pancreatic necrosis
Lankisch.Acute Pancreatitis. Springer Verlag 1987
Irritable Bowel Syndrome Definition: Symptoms of lower gastrointestinal like
diarrhea, constipation or combination with abdominal cramps/pain. No organic abnormality found in colonoscopy.
Pathogenesis: stress, hypersensitivity, abnormal serotonin, abnormal motility etc.
Management:
- Diet rich of fibre
- Anti Anxiety-Depression
- Constipation: Prokinetic , 5 HT 4 agonist
- Diarrhea: Antispasmodic, anticholinergic
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
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