EXAMINATION OF THE GI TRATCT

Aim: Optimal use of endoscopic and/or radiologic imagingtechniques to reach maximal information without causing less

trouble for the patient

Essential roleof GI tract

• Absorption of nutritients

• Excretion

• Maintaining coordinated passage

Approachto thepatient

• To take thorough history

• Physical examination

• Laboratory investigations (blood,stool,gastric juice,etc)

• Ultrasound

• Endoscopy

• X-ray

• CT, MRI, angiography, isotope scan,PET, selective enterography, capsullar video endoscopy

HISTORYwhen, where, how, what, what is it

like?• ABDOMINAL PAIN• ALTERATION IN BOWEL HABIT• Difficulties in swallowing, NAUSEA,

VOMITUS• BLEEDING: hemathemesis, melena,

hematochezia• GENERAL MEDICAL HISTORY• FAMILY HISTORY

Main principles

• Immediate distinctionbetweenurgentproblemandnonacute disorder

• Determinationof the temporalevolutionof symptomes andto be ableto differentiate betweenorganic andpsychosomatic alterations

• Consider all informations toavoidunnecessarytests inthe workup

Problemsof swallowing

• 1. determination the nature of dysphagia: difficulty in swallowing liquids, solids or both. Careful oropharingeal examination is needed

• 2. oesophageal bariumX-ray studies• 3. oesophagoscopy: to obtain biopsy specimen

from a lesion causing filling defect on X-Ray, thediagnosis of peptic oesophagitis or Barett’soesophagus are based only on endoscopy; sclerotherapy of oesophageal and gastric variciescould be performed exclusively by this tool

Oesophagus malformationshownbybariumcontrast

ABDOMINAL PAIN

• Acute /chronic

• Characterization: sharp, cramping, burning

• Intensity: acceptable-intolerable

• Localization: upper/lower; localized/diffuse, radiating

• Relationship to meals: on fasting,whileeating, shortly after/or 30-90 min later

Commoncauses of abdominal pain

• Gastrointestinal causes:Acute and chronic cholecystitis, Appendicitis, bowel

obstruction, constipation, diverticular disease, gastroenteritis, IBD, irritable bowel, pancreatitis, peptic ulcer and reflux disease, tumors

• Extraintestinal causes: Abdominal aorticaenurysm, Dysmenorrhea, Epididymitis, Incomplete abortion, Nephrolithiasis, Ovariancyst, Pelvic inflammatory disease, Pregnancy, ÚTI, Pb intoxication, Porphyria

Alterationin bowel habit

• Diarrhoea and/or constipation: consider intestinalor extraintestinal cause

• Evaluating with the related symptomes (weightloss, fever, bloating….)

• Stool:determination of frequency, consistency, colour, if any blood is present, presence of mucus and pus,

• Nocturnal diarrhoea consider always as organic

Factors anddisorders associatedwith constipation

• General: lack of physical activity (eg.hospitalization), lackof fiber in the diet

• Systemic: side effect of drugs ( antacids, analgesics, psychopharmacologic agents,iron ), Endocrine disorders( hypothyreoidism, hyperparathreoidism), reflectory innephrolithiasis, and in pancreatitisMetabolic disorders ( hyper Ca, uraemia, hypoK)

• Colonic: Obstruction, IBS, Diverticular disease, Painfulanorectal disorders

• Neurogenic: Hirschprung’s disease, CNS disorders, Diabetic neuropathy, Psychogenic cause

Commoncausesof diarrhoea

• Infection:Viral, bacterial, parasite infestation (e.g. amoeba)

• Diet and drugs: much alcohol, a reaction to certainmedications, or a food intolerance.

• GI diseases that cause diarrhoeaCrohn's disease, ulcerative colitis, irritable bowelsyndrome, gastrointestinal tumours, andmalabsorption syndromes such as coeliac disease.

• Extraintestinal diseases: hyperthyreoidism, functional- psychogenic

Physical examination1.

• Inspection: colour: paleness or icterus, nutritional condition, contour: enourmouslylarge masses, ascites, fistulas in the perianalregion, forced movement of the bowel maybe seen

• Auscultation: absence of bowel sounds inevolving ileus or an obstructing process, orsuccusion splash-in gastric outlet obstruction

Physical examination2.

• Palpation: detecting tenderness and massesRebound tenderness (direct or referred) after removal of the

examining hand is a clue to localized or generalizedperitonitis, abdominal emergencies.

Rectal digital examination: masses intrinsic to the rectum, abnormalities in the pelvis, on the punch of the Douglas, presence or absence of fresh bright red bloody or maroonstool.

• Percussion: to assess free air beneath the diaphragm, andliver and spleen size, bladder content

Laboratorytests

• Total blood count, ESR, liver enzymes, bilirubin, amylase-lipase

• Tumour-markers (CEA,α FP, CA19.9)• For malabsorption: stool fat by sudan, starch by

iodine reaction, muscle remnants by lightmicroscopic evaluation

• D-xylose absorption test to separate mucosaldisease frompancreatic insufficiency

• For Lactose intolerance: Hydrogen breath test• For Helicobacter Pylori: 13Carbon urea breath test

Ultrasound(US)+doppler

• Usefull in delineation of abdominal massess• To determine wall tickness (stomach…)• To find stones and backward dilatation of ducts ( bile, and

ureter, pyelon) and pancreatic and renal cysts• To determine TNM stadiumof tumours• To assess blood flowin deep veins• To find and monitor aortic aneurysma• For monitoring and followup (cure/relaps)• Help in perfoming US guided needle biopsies fromliver

Severe stricture of the esophagus

Contraindication

Guided biopsies and cytology of mass lesions

Staging of carcinoma of the esophagus

Differential diagnosis of submucosal lesions of the esophagus

Indications

Endoscopic ultrasonography

ENDOSCOPOPY

• THIS PROCEDURE ALLOWS FOR DIRECT INSPECTION OF THE MUCOSA AND THE LESION ITSELF

• permit to identify and differentiate between peptic andneoplastic ulcerating lesions

• to find the bleeding site and to perfomcauterization• PERMITTING DETECTION OF: -CANCERS AND

POLYPS (that may be missed by bariumX-ray studies),-inflammatory changes of the mucosa,

• to diagnose HP, performing biopsies and polypectomy

Endoscopy( flexible fiberopticinstrument) forms

• Gastroduodenoscopy• Colonoscopy• Sigmoidoscopy (rigid): for identifying the lower 25 cm of

the colon• Recto,- anoscopy (rigid)• ERCP• Selective enterography• Capsullar video endoscopyRadiologic examination may be only preferred whenthere are contraindications to safe endoscopy

Patients who are hemodynamically unstable

Dysphagic patient who has not had an esophagogramrecentlyPatients with suspected perforated viscus

Patients who are moribund

Patients with large Zenker's diverticulumPatients who are unable to cooperate

Relative ContraindicationsAbsolute Contraindications

Contraindications to endoscopy

Upper gastrointestinal endoscopy:permitsevaluation of the esophagus, stomach, duodenum;

ERCP: permits inspection and canulation of thepapilla Vateri, and visualise the architecture ofpancreas, ductal dilatations, the branching of thebile ducts,

to performpapillotomy and stent implantationColonoscopy: visualise the entire colon, the terminal

ileumand the colonic polyps can be removed.

Removal of foreign body

Laser therapy of esophageal and gastroesophageal malignancies

Stent placement in palliative therapy of malignant stricture

Sclerotherapy and banding of varices

Dilatation of strictures, both benign and malignant

Therapeutic

Abnormal results of barium esophagogram

Cancer surveillance (eg, Barrett's esophagus)

Patients with suspected infectious esophagitis

Certain patients with suspected gastroesophageal reflux disease

Dysphagia and odynophagia

Diagnostic

Indications for endoscopy of the esophagus

ERCP

X-ray studies

• First choice for determining free air (sign of perforatedviscus) on plain film

• First choice to confirmileus (nivous in the small or largeintestine) on plain film

• Best in assessing motility and alterations of small intestinerelatively inaccessible to fiberoptic instruments.

• When endoscopy is contraindicated: severe ulcerativecolitis: bariumenema with air contrast techniques,

• For visualisation of fistulas• With absorbeable contrast media: to find cause of recurrent

pneumonias and aspiration

Chron’s disease. Bariumenema

Other toolsfor visualization

• CT,MRI: TNM staging

• PET(positron emission tomography) in caseof question

• Promt mesenteric angiography: in suspicionof vascular disease: mesenteric ischaemiaand bleeding fromthe small intestine

• Isotope scan

Case presentation of a 21yrs old ♂

The only symptome is fever38 C for 3 months

• Physical examinaton: normal• abd. US normal• CRP: 27,58, ESR: 22 mm/h• Sources of infection by ORL consultation were disclosed• Thyroid function, immun panel tests: negative• viral serology: CMV, EBV IgG positive• Echocardiograpy: normal, • After a month thorough followup he tells us that he missed to tell that he found

the stool bloody- he did not think that it might have significance ( psychosomatic alteration is to be suspected)

• Panendoscopy: duodenal ulcer• Repeated US ( 2 months apart) revelaed inhomogenity inthe spleen, therefore• Abd CT had been performed before colonoscopy: the ileumseemed to be

tickened by this method

SelectiventerographyrevealedChron’s disease.

BLEEDING DIVERTICULUM ANGIOGRAPHY

Izotop-taggedredbloodcell

Casepresentation

Complain:melaena

Gastroscopy: negative

Colonoscopy: negative, but fromthe coecum(valv Bauhin) blackstool appearedmeaningthatthe bleedingis originatedfrom the small bowel

But, in the present caseextravasationwas not seen

Szelektív angiográfia:

This is a positive finding

In the first part of the jejunum appr. 10-12 cm long in the arterial phase pathologicalvessel structure was seen. AV malformation? Therefore capsullar enterographia had

been indicated. According to that result the patient had been operated

CT ENTEROGRAPHY

( not shown)

angiodysplasia

Reasonsof small bowel bleedingare

Angiodysplasia andarterial malformatio ( 30-40% ),

Otheres less frequently:

NSAID enteropathy, Erosive jejunitis-ileitis,Diverticular ( Meckel ),Crohn’s diseaseIntussusception, tumors: leiomyoma, carcinoid, lymphoma, adenocc., Ischaemiás enteropathy, Aortoenteral fistula

50 % the bleeding source remain unknown after theupper and lower ract endoscopy had been performed

Push – enteroscopy or capsular endoscopy is indicatedin these cases when others,like CT - MR enterography, radioizotop scan and angiográfia failed.

After thorough examination still 5% of bleedingsremain obscure

JEJUNUM ANGIODYSPLASIA

Seenoncapsullar enterography