Transcript Document

CLINICAL FEATURES and
INVESTIGATIONS in
GASTROENTEROLOGY
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Sensation of “sticking” or obstruction of the
passage of food through the mouth, pharinx or the
esophagus.
Dysphagia (D) should be distinguished from other
symptoms related to swallowing.
Aphagia – complete esophageal obstruction –
medical emergency
Difficulty in initiating a swallow occurs in
disorders of the voluntary phase of swallowing
Odynophagia (O) painful swallowing
Frequently O + D occur together
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Globus hystericus – sensation of a lump lodged in
the throat.
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Phagophobia – fear of swallowing
 Refusal
to swallow: hysteria, rabies, tetanus,
pharyngeal paralysis
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Feeling of fulness in the epigastrium after a
meal or swallowing air ≠ dysphagia
Approach to the patient with D
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History – diagnosis in 80% of patients
The type of food – useful information
Difficulty only with solids – mechanical D; the lumen
is not severely narrowed (drinking liquids through the
narrowed area force the impacted bolus)
Advanced obstruction – D with liquids/solids
Motor D (achalasia + esophageal spasm) total D from the
onset
Scleroderma – D to solids unrelated to posture/liquids
in the recumbent, but not in the upright posture
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Peptic stricture developes – D became more persistent
The duration and course of D – helpful in diagnosis
Transient D of short duration – inflammatory process
Progressive D of a few weeks to a few month’s
duration – carcinoma of the esophagus
Episodic D to solids of several years duration – benign
disease of the esophageal ring
Associated symptoms provide important diagnostic clues
Nasal regurgitation
tracheobronchial aspiration + swallowing
hallmarks of pharingeal paralysis/tracheoesophageal fistula
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Tracheobronchial aspiration unrelated to swallowing
ACHALASIA
ZENKER’S DIVERTICULUM
GERD
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Severe weight loss – carcinoma
Hoarseness – precedes/following D →
 larynx
primary lesion,
 recurrent laryngeal nerve caused by extension of
esophageal carcinoma
laryngitis secondary GER
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Hiccups suggest lesion in the distal portion of
esophagus
Unilateral wheezing + D → mediastinal mass →
esophagus/large bronchus
Chest pain + D → esophageal spasm (motor
disorders)
Prolonged history of heartburn and GER preceding D
→ PEPTIC STRICTURE
•Prolonged nasogastric intubation
•Ingestion of caustic agents
•Previous radiation therapy
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causes of esophageal
strictures
Odynophagia: candidal, herpes esophagitis suspected
AIDS → esophagitis
PHYSICAL EXAMINATION
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Important in motor D due to skeletal muscle, neurologic,
oropharyngeal diseases
Neck → thyromegaly/spinal abnormality
Careful inspection of the mouth + pharynx → lesion →
pain/obstruction
Changes in the skin, extremities
Scleroderma
 Collagen vascular diseases
 Mucocutaneous diseases(pemphigoid,epidermolysis bullosa)
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Pulmonary complications – acute aspiration pneumonia
Metastatic diseases to limph nodes and liver
DIAGNOSTIC PROCEDURES
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BARIUM SWALLOW + CINERADIOGRAPHY
ESOPHAGOGASTROSCOPY+BIOPSY+EXFOLIATIVE CYTOLOGY
ESOPHAGEAL MOTILITY
PH-METRY
ESOPHAGEAL IMPEDANCE
ECHOENDOSCOPY
COMPUTER TOMOGRAPHY
MAGNETIC RESONANCE
ANOREXIA (A)
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In diseases of GIT and liver
It may precede the jaundice in Acute Hepatitis
Prominent symptom in gastric carcinoma
A ≠ SITOPHOBIA (fear of eating because of
subsequent abdominal discomfort)
A may be a prominent feature of extraintestinal
diseases
Chronic pain from any source →loss of appetite
In cancer, A results from anxiety, pain, decreased
sense of taste + smell, effects of the tumor on the
GIT (tumor necrosis factor)
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Medications: Antihypertensive
Diuretics
Digitalis
Narcotic analgesics
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Psychogenic disturbances – A nervosa
Congestive heart failure/Respiratory failure
Endocrinopathies/hyperparathyroidism, Addison’s
disease
Mechanism of hunger + apetite
Food intake is reglated by 2 hypotalamic centers:
Lateral “feeding center”
 Ventromedial “satiety center”
 CCK (brain gut peptide) – satiety effect
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NAUSEA AND VOMITING
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common manifestations of many organic/functional
disorders
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ACUTE ABDOMINAL EMERGENCIES leads to “SURGICAL
ABDOMEN”
 acute appendicitis
 acute cholecystitis
 intestinal obstruction
 acute peritonitis
DISORDERS OF THE ALIMENTARY TRACT
 peptic ulcer
 GI motility disorders
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Postvagotomy
Diabetus
Idiopathic gastroparesis
Liver, pancreas, biliary tract disorders
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VIRAL, BACTERIAL, PARASITIC INFECTIONS OF THE IT
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ACUTE SYSTEMIC INFECTIONS – young children → FEVER
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CENTRAL NERVOUS SYSTEM DISORDERS
 neoplasms
 encephalitis
 Meniere’s disease
 migraine headaches
 acute meningitis
ACUTE MYOCARDIAL INFARCTION
 CONGESTIVE HEART FAILURE
CANCER – patients terminally ill
METABOLIC + ENDOCRINOLOGIC DISORDERS
HYPEREMESIS GRAVIDARUM
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SIDE EFFECTS OF DRUGS:
 digitalis
 morphine
 chemotherapeutic agents
 ingestion of a toxic (food poisoning)
PHYCHOGENIC VOMITING: anorexia nervosa, bulimia
Relationship of vomiting (V) to eating → diagnostic
V that occurs in the morning: pregnancy, uremia
 Alcoholic gastritis – early-morning retching, emesis
V shortly after eating → peptic ulcer + pylorospasm
V 4-6 h after eating → pyloric obstruction, esophageal
disorders (achalasia, Zenker’s diverticulum)
Relief of abdominal pain with vomiting → peptic ulcer
rarely satiety → gastroparesis
INDIGESTION
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represents a challenging + difficult diagnostic
problem because of its nonspecific nature
Abdominal pain – evaluated with Rx, imaging studies
of the esophagus, stomach, small intestine, colon,
pancreas,biliary tract.
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ESOPHAGOGASTROSCOPY
 ERCP
 COLONOSCOPY
Empiric trials of antiacids, H2-Rblocking drugs or sucralfat
are used in patients < 40 years with epigastric pain
SDE- persistent symptoms despite therapy/recur soon after
discontinued therapy
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H pylori patients – oral AB 7 days after SDE + biopsy
Excessive gas, bloating, distension, flatulence →
questionary: dietary preferences
relation of symptoms to specific foods
 Elimination of milk, legumes from the diet → confirmatory
NONULCER DYSPEPSIA-disturbances of GI motility
Esophagus-Substernum,epigastrium-Peptic
esophagitis,stricture,esophageal spasm,carcinoma
Stomach-Epigastrium-Gastritis,gastric ulcer,carcinoma
Duodenum1+2-Epigastrium-Duodenal ulcer
Small intestine-Periombilical-Enteritis,lymphoma,obstruction
Gallbladder,pancreas,liver-Epg.,right,left upper qt.,backCholelithiasis,Pancreatitis,Hepatitis,Cirrhosis,carcinoma.
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Colon-below umbilicus-UC,carcinoma,obstruction
Non-ulcer dyspepsia-20-30% of population
Helicobacter pylori + chronic gastritis
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Heartburn (pyrosis):
reflux of acid/bile into the esophagus
 after a large meal
 in supine
 Fluid in the mouth: salty (“water brash”)
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sour (gastric contents)
bitter green/yellow (bile)
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After citrus fruit juices, drugs (alcohol, aspirin)
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Food intolerance
Carcinoma -discomfort for solids
 Citrus ↓ pH → peptic ulcer, esophagitis
 Deficiency of a specific enzyme (lactase-milk)
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abdominal cramps
 distention
 diarrhea
 flatulence
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Allergic reactions – urticaria, angioedema, asthma
 Toxic effects – gluten in celiac sprue
 History of fatty food intolerance or distress after spicy
foods is commonly in patients with indigestion
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ERUCTATION (BELCHING)
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Chronic anxiety
Rapid eating
Drinking carbonated beverages
Gum chewing
Postnasal drip
Poorly fitting dentures
20-60% of intestinal gas is swallowed air
gastric bubble syndrome
splenic flexure syndrome-fullness in left upper quadrant with
radiation to the left side of the chest
↑ tympany + air in the splenic flexure of the colon on a plain
abdominal radiograph
GASEOUSNESS, BLOATING, FLATULENCE
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Motility disturbances
Fermentative action of intestinal bacteria or carbohydrates
and proteins within the lumen
CO2 small intestine → HCl, ingested fatty acids are neutralized
by bicarbonate
1/3 of adults produce methane in the colon unrelated to
food ingestion
Ex. Beans contain oligosaccharides that can’t be split by
intestinal mucosal enzymes, but are metabolised by colonic
bacteria
Increased intraluminal gas may result from abnormal
bacterial colonization of the small intestine or infection
with Giardia lamblia
WEIGHT GAIN
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CAUSES OF OBESITY
Excess caloric intake
 Cushing’s syndrome
 Hypothyroidism
 Hypogonadism
 Insulin-secreting tumors
 Cranyopharyngioma (disense of hypotalamus)
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WEIGHT LOSS
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more often a diagnostic problem than weight gain, a
sign of serious organic illness.
DIABETES MELLITUS
↑ insulin-dependent form (insulin deficiency +
↑ glucagon) cause accelerated proteolysis and lipolysis
→ net energy state is catabolic
 Weight loss is associated with increased food intake
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ENDOCRINE DISEASE
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THYROTOXICOSIS
PHEOCHROMOCYTOMA → catecholamine release
PANHYPOPITUITARISM
ADRENAL INSUFFICIENCY → cortisol deficiency
GASTROINTESTINAL DISEASE
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Inflammatory bowel disease
Parasites
Esophageal strictures
Chronic peptic ulcer
Pernicious anemia
Cirrhosis liver
INFECTION
Tuberculosis
Fungal disease
Amoebic abcess
Subacute bacterial endocarditis
HIV
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Cause: inflammatory cytokines
MALIGNANCY
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GIT
Pancreas
Liver
Lymphoma
Leukemia
PSYCHIATRIC DISEASE
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Schizophrenia
Depression
RENAL DISEASE
GASTROINTESTINAL BLEEDING
- etiology Upper GI Bleeding
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Peptic ulcer
Gastritis
Varices
Mallory-Weiss syndrome
Gastric carcinoma
Lymphoma
Polyps
Dyscrasias, vasculitis
Lower GI Bleeding
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Anal + rectal lesions
Colonic lesions, carcinoma,
angiodysplasia, UC, ischemic
colitis
Diverticula Meckel’s
congenital distal ileum – 2%
HISTORY
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Ulcer disease
Recent heavy use of alcohol/AIND → erosive
gastritis, esophageal varices
Aspirin → gastroduodenitis
peptic ulceration bleeding
Acute onset of bloody diarrhea → IBD
PHYSICAL EXAM
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DERMATOLOGIC
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telangiectasia Osler-Weber-Rendu
perioral pigmentation of Peutz-Jeghers
diffuse pigmentation hemochromatosis
spider angiomata
gynecomastia
testicular atrophy
jaundice
ascites
hepatosplenomegaly – HTP → varices
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abdominal mass → malignancy
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RECTAL EXAMINATION → local pathology
color of the stool
LAB STUDIES
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Hb, Ht, WC, IP
Radiography of the abdomen → perforation,
ischemia is suspected
Repeated evaluation of the lab data-clinical course
of the bleeding.
CONSTIPATION and DIARRHEA
-functional and organic disorders
IRRITABLE BOWEL,colonic
tumors,IBD,mucosal disorders ,sprue,pancreatic
insufficiency,postgastrectomy,endocrine
diseases,habitual.
DIAGNOSTIC
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ENDOSCOPY: diagnostic
treatment: coagulation Nd-YAG laser,
elecrocautery, sclerotherapy of varices
ANGIOGRAPHY: localise the site of bleeding
intraarterial infusions of vasoconstrictor
agents/vasopressin
COLONOSCOPY: GI bleeds,
polypectomy/electrocoagulation
Barium enema – limited role
Arteriography – active blood loss > 0,5 ml/min
Bleeding scans