Gastroenterology Gastroenterology ReviewReview

Gastroenterology HistoryGastroenterology History Dyspepsia & HeartburnDyspepsia & Heartburn Dysphagia & OdynophagiaDysphagia & Odynophagia Nausea and vomitingNausea and vomiting Abdoinal painAbdoinal pain Abdominal swellingAbdominal swelling Appetite/weight gainAppetite/weight gain DiarrhoeaDiarrhoea ConstipationConstipation BleedingBleeding JaundiceJaundice PruritusPruritus

DyspepsiaDyspepsia&&

Peptic Ulcer Peptic Ulcer DiseaseDisease

DYSPEPSIA DYSPEPSIA (INDIGESTION )(INDIGESTION )

UPPER ABDOMINAL UPPER ABDOMINAL SYMPTOMSSYMPTOMS

*EPIGASTRIC PAIN .*EPIGASTRIC PAIN .

*BLOATING.*BLOATING.

*FULLNESS.*FULLNESS.

* BELCHING. * BELCHING.

*HEARTBURN .*HEARTBURN .

*NAUSIA & VOMITING*NAUSIA & VOMITING

*EARLY SATIETY.*EARLY SATIETY.

DyspepsiaDyspepsia Common problem in the community - affects Common problem in the community - affects

up to 40% of individuals in 1 yearup to 40% of individuals in 1 year Up to 60% of patients do not have an Up to 60% of patients do not have an

identifiable organic cause - “functional”identifiable organic cause - “functional” Nevertheless can be the presenting symptom Nevertheless can be the presenting symptom

of a number of serious conditionsof a number of serious conditions May be the only symptom of malignancyMay be the only symptom of malignancy Has Eesophageal, Stomach and Duodenal Has Eesophageal, Stomach and Duodenal

pathologiespathologies May indicate underlying gallstone diseaseMay indicate underlying gallstone disease Warrants OGD in patients over 55 or with Warrants OGD in patients over 55 or with

alarming symptoms & signsalarming symptoms & signs

Etiology of DYSPEPSIAEtiology of DYSPEPSIA 1-NON-ULCER (Functional) DYSPEPSIA (50 % ).1-NON-ULCER (Functional) DYSPEPSIA (50 % ). {Dyspepsia of at least 3 Months duration for which no {Dyspepsia of at least 3 Months duration for which no

biochemical or structural abnormality is found to biochemical or structural abnormality is found to explain the patients symptoms }.explain the patients symptoms }.

2- PEPTIC ULCER DISEASE (20 % ).2- PEPTIC ULCER DISEASE (20 % ). 3-REFLUX ESOPHAGITIS (15 – 20 % ).3-REFLUX ESOPHAGITIS (15 – 20 % ). 4-N.E.R.D,Motility disorders4-N.E.R.D,Motility disorders 5 -Pancreatico-Biliary Disorders. 5 -Pancreatico-Biliary Disorders. 6- Medications :NSAIDs ,Antibiotics ,Theophyllins , Irons.6- Medications :NSAIDs ,Antibiotics ,Theophyllins , Irons.7-Dietary factors :Caffeine , Alcohol.7-Dietary factors :Caffeine , Alcohol.8- Metabolic & Endocrine : D.M , Hyperthyroidism ,8- Metabolic & Endocrine : D.M , Hyperthyroidism ,9-H .pylori.9-H .pylori.

10 –GASTRIC MALIGNANCY Is found in 1 – 2 % of 10 –GASTRIC MALIGNANCY Is found in 1 – 2 % of patients with dyspepsia, Age > 55 years + Alarm patients with dyspepsia, Age > 55 years + Alarm

symptoms.symptoms.

SYMPTOM PATTERNS IN DYSPEPSIASYMPTOM PATTERNS IN DYSPEPSIA

Ulcer-type symptoms Ulcer-type symptoms Epigastric pain Relief with food Epigastric pain Relief with food or Antacid or Antacid

Pain worse Pain worse at nightat night

Reflux symptoms Reflux symptoms Acid Acid regurgitationregurgitation

HeartburnHeartburn U.G.I. FlatulenceU.G.I. Flatulence Retrosternal painRetrosternal pain

Dysmotility symptomsDysmotility symptoms Anorexia /Early satietyAnorexia /Early satiety Postprandial Postprandial

bloatingbloating Nausea & or VomitingNausea & or Vomiting

DyspepsiaDyspepsia

FunctionalFunctionalDyspepsiaDyspepsia

Non-GI CausesNon-GI Causes(cardiac disease,(cardiac disease,

muscular pain, etc.)muscular pain, etc.)

Structural DyspepsiaStructural Dyspepsia(GERD, PUD, Pancreatic(GERD, PUD, Pancreaticdisease, Gallstones, etc.)disease, Gallstones, etc.)

(Alarm Symptoms & Signs)(Alarm Symptoms & Signs)Indicators for investigationIndicators for investigation

Vomiting (persistent)Vomiting (persistent) Bleeding/anaemiaBleeding/anaemia Abdominal mass/unexplained Abdominal mass/unexplained

weight lossweight loss Dysphagia (progressive)Dysphagia (progressive) (Age > 55)(Age > 55)

Hiatal Hernia and Hiatal Hernia and Gastroesophageal RefluxGastroesophageal Reflux

GERDGERD

Gastroesophageal reflux Gastroesophageal reflux (GERD)(GERD)

GER is the reflux of chyme from the stomach GER is the reflux of chyme from the stomach to the esophagusto the esophagus

If GER causes inflammation of the If GER causes inflammation of the esophagus, it is called reflux esophagitisesophagus, it is called reflux esophagitis

A normal functioning lower esophageal A normal functioning lower esophageal sphincter maintains a zone of high pressure sphincter maintains a zone of high pressure to prevent chyme refluxto prevent chyme reflux

Conditions that increase abdominal pressure Conditions that increase abdominal pressure can contribute to GER can contribute to GER

More common in people with hiatus herniaMore common in people with hiatus hernia ManifestationsManifestations

Heartburn, regurgitation of chyme, and upper Heartburn, regurgitation of chyme, and upper abdominal pain within 1 hour of eatingabdominal pain within 1 hour of eating

Characteristics of Heartburn

EpidemiologyEpidemiology ~~25% of the adult population 25% of the adult population

experience symptoms at least monthlyexperience symptoms at least monthly 5% experience daily symptoms.5% experience daily symptoms. Incidence increases with ageIncidence increases with age

““Alarm Symptoms” Alarm Symptoms” Urgent referral for endoscopy for patients Urgent referral for endoscopy for patients

of any age with dyspepsia when of any age with dyspepsia when presenting with any of:presenting with any of: Chronic gastrointestinal bleeding Chronic gastrointestinal bleeding Progressive unintentional weight loss Progressive unintentional weight loss Progressive difficulty swallowing Progressive difficulty swallowing Persistent vomiting Persistent vomiting Iron deficiency anaemiaIron deficiency anaemia Epigastric massEpigastric mass Choking (acid causing coughing, shortness of breath , Choking (acid causing coughing, shortness of breath ,

or hoarsness) or hoarsness) Chest painChest pain Longstanding symptoms requiring continuous Longstanding symptoms requiring continuous

treatmenttreatment

DiagnosisDiagnosis Therapeutic trial (3 months)Therapeutic trial (3 months) Endoscopy Endoscopy

Alarm sxAlarm sx To note mucosal changesTo note mucosal changes Esophageal biopsiesEsophageal biopsies

Motilitiy studiesMotilitiy studies Low LES pressures are associated with refluxLow LES pressures are associated with reflux

pH monitoring pH monitoring ( GOLD STANDARD )( GOLD STANDARD ) The most precise measure for the presence The most precise measure for the presence

of acid in the esophageal lumen (24 hour of acid in the esophageal lumen (24 hour monitoring)monitoring)

GERD ComplicationsGERD Complications Benign strictureBenign stricture PerforationPerforation HaematemesisHaematemesis Barrett’s oesophagusBarrett’s oesophagus

>3cm columnar epithelium in lower 1/3 of oesophagus

Must be confirmed by biopsy

Risk of adenocarcinoma (20% for low grade dysplasia, 50% for high grade displasia

Monitor with OGD, PPI, ? Oesophagectomy for high grade dysplasia in young fit adults

GERD ManagementGERD Management Advice – weight loss, stop smoking, stop Advice – weight loss, stop smoking, stop

alcohol, avoid stoopingalcohol, avoid stooping Medical – exclude CA if >55, control acid Medical – exclude CA if >55, control acid

secretion (PPI/Hsecretion (PPI/H22antagonist), protect antagonist), protect oesophagus (alginates), prokinetics oesophagus (alginates), prokinetics (metoclopramide)(metoclopramide)

Surgical –Surgical – Nissen fundoplication Nissen fundoplication Failed medical management Failed medical management Complications Complications Long term dependance on medical therapyLong term dependance on medical therapy

Peptic Ulcer DiseasePeptic Ulcer Disease A break in the epithelium of the A break in the epithelium of the

oesophagus, stomach or duodenumoesophagus, stomach or duodenum 5 – 10% of the general population will have 5 – 10% of the general population will have

PUD in their lifetime, 50% will recurPUD in their lifetime, 50% will recur Due to Imbalance between protective and Due to Imbalance between protective and

aggressive factorsaggressive factors Investigations – FBC, FOB, OGD, Investigations – FBC, FOB, OGD,

Urease breath testUrease breath test 0001% mortality rate0001% mortality rate

Gastric Mucosa & SecretionsGastric Mucosa & Secretions

The Defensive Forces

Bicarbonate

Mucus layer

Mucosal blood flow

Prostaglandins

Growth factors

The Aggressive ForcesHelicobacter pylori

HCl acid

Pepsins

NSAIDs

Bile acids

Ischemia and hypoxia.

Smoking and alcohol

Peptic UlcerPeptic Ulcer

EtiologyEtiology H.PyloriH.Pylori

Almost all patients with H. pylori have antral gastritisAlmost all patients with H. pylori have antral gastritis Eradication of H. pylori eliminates gastritisEradication of H. pylori eliminates gastritis Nearly all patients with DU have H. pylori gastritisNearly all patients with DU have H. pylori gastritis 80% of patients with GU have H. pylori gastritis80% of patients with GU have H. pylori gastritis

DrugsDrugs NSAIDSNSAIDS CorticosteroidsCorticosteroids

HyperacidityHyperacidity Zollinger – Ellison SyndromeZollinger – Ellison Syndrome

Cigarette smoking Cigarette smoking Rapid gastric emptyingRapid gastric emptying

No effect of spicy foods

Helicobacter pyloriHelicobacter pylori

DU

GU

80% 95%

H pylori and diseaseH pylori and diseaseHalf of worlds population infectedHalf of worlds population infected

100 %100 % damage to gastric structuredamage to gastric structure

Many infected indiviudals no (silent) diseaseMany infected indiviudals no (silent) disease

17 % 17 % Peptic UlcerPeptic Ulcer ((90 – 95 90 – 95 % duodenal ulcer patients% duodenal ulcer patients has has Hp)Hp)

((7070 – 85 – 85 % gastric ulcer patients% gastric ulcer patients has Hp)has Hp)

2 %2 % G Gastric carcinomaastric carcinoma ((8585 % % of of patients patients has Hp)has Hp)

X %X % Nonulcer dyspepsiaNonulcer dyspepsia (5(500 % non ulcer dyspepsia patients% non ulcer dyspepsia patients))

MALT lymphomaMALT lymphoma Coronary Artery DiseaseCoronary Artery Disease

NSAIDs:NSAIDs: Prevalence of Endoscopic NSAID-Induced Prevalence of Endoscopic NSAID-Induced

UlcerationUlceration

MeanMean Range Range

Gastric UlcerGastric Ulcer 15 % 15 % 10 to 10 to 30%30%

Duodenal UlcerDuodenal Ulcer 5 % 5 % 4 4 to 10 %to 10 %

Clinically Significant Ulcers 2%Clinically Significant Ulcers 2% 1 to 4%1 to 4%

Risk Factor AnalysisRisk Factor Analysis Family History:Family History: For both DU and GU, FH pattern appears distinct: 1For both DU and GU, FH pattern appears distinct: 1stst-degree -degree

relatives of DU patients have a 3x increase in DU; in contrast, relatives of DU patients have a 3x increase in DU; in contrast, relatives of patients with GU have a 3x increase in the GU.relatives of patients with GU have a 3x increase in the GU.

Smoking:Smoking:Evidence supports an association between smoking Evidence supports an association between smoking

and PUD in H. pylori infected subjects, but it does and PUD in H. pylori infected subjects, but it does not increase the recurrence of peptic ulcers after not increase the recurrence of peptic ulcers after successful eradication of H. pylori.successful eradication of H. pylori.

Dietary fatDietary fat:: N No associationo association Coffee:Coffee: N No associationo association High stress / Type A:High stress / Type A: In a case-control study: In a case-control study:

quantifying the # of stressful life events and distress quantifying the # of stressful life events and distress scores did not differentiate patients with DU from scores did not differentiate patients with DU from age-matched controls.age-matched controls.

Clinical PresentationClinical Presentation

Recurrent Epigastric PainRecurrent Epigastric Pain (The most common (The most common symptom)symptom) BurningBurning

Hunger Pain ( Occurs 1-3 hours after meals )Hunger Pain ( Occurs 1-3 hours after meals )

Relieved by food Relieved by food DUDU

Precipitated by food Precipitated by food GUGU Relieved by antacidsRelieved by antacids

Radiate to back (consider penetration)Radiate to back (consider penetration)

Pain may be absent or less characteristic in one-third of Pain may be absent or less characteristic in one-third of patients especially in elderly patients on NSAIDspatients especially in elderly patients on NSAIDs

Duodenal Ulcer and Type II Duodenal Ulcer and Type II Gastric Ulcer (Prepyloric and Gastric Ulcer (Prepyloric and

Antral)Antral) MaleMale Hunger pain, relieved by food, Hunger pain, relieved by food,

periodicityperiodicity Back pain if ulcer is penetratingBack pain if ulcer is penetrating Posterior erosion – haematemesisPosterior erosion – haematemesis Anterior erosion – peritonitisAnterior erosion – peritonitis Pyloric stenosis – gastric outflow Pyloric stenosis – gastric outflow

obstructionobstruction

Type I Gastric Ulcer (Proximal)Type I Gastric Ulcer (Proximal)

Less male predominance (still more Less male predominance (still more common in males)common in males)

Older age group (>50)Older age group (>50) Epigastric pain worse on eatingEpigastric pain worse on eating Weight lossWeight loss Nausea and vomitingNausea and vomiting Gastritis and chronic anaemiaGastritis and chronic anaemia

Peptic Ulcer DiseasePeptic Ulcer Disease Duodenal UlcersDuodenal Ulcers 20 to 50 years old20 to 50 years old High stress occupationsHigh stress occupations Genetic predispositionGenetic predisposition Pain when stomach is Pain when stomach is

emptyempty Pain at nightPain at night Frequency = 4 times more Frequency = 4 times more

common than gastric common than gastric ulcersulcers

Usually associated with Usually associated with hyperacidityhyperacidity

Gastric UlcersGastric Ulcers > 50 years old> 50 years old Work at jobs Work at jobs

requiring physical requiring physical activityactivity

Pain after eating or Pain after eating or when stomach is when stomach is fullfull

Usually no pain at Usually no pain at nightnight

H. Pylori DiagnosisH. Pylori Diagnosis

Serology– 90% sensitive, 95% specific – Serology– 90% sensitive, 95% specific – not good for following treatmentnot good for following treatment

Biopsy– 98% sensitive – 98% specificBiopsy– 98% sensitive – 98% specific Urea breath test– 95% specific, 98% Urea breath test– 95% specific, 98%

specific – can be used to document specific – can be used to document eradicationeradication

Stool antigen test – 90% sensitive, 95% Stool antigen test – 90% sensitive, 95% specific – can be used to confirm specific – can be used to confirm eradication eradication

Natural HistoryNatural History 20 – 50% heal untreated20 – 50% heal untreated 80% heal in 4 weeks of treatment80% heal in 4 weeks of treatment 75% recur in 6 – 12 months75% recur in 6 – 12 months More recur in patients with More recur in patients with

H. pylori, smokers, NSAID usersH. pylori, smokers, NSAID users Milk and tobacco slow healingMilk and tobacco slow healing

Management of Peptic Management of Peptic UlcerationUlceration

Medical :Medical : Eradication therapy for H pyloriEradication therapy for H pylori ( Tripple Therapy )( Tripple Therapy )

Surgical – Elective treatment for ulcers Surgical – Elective treatment for ulcers no longer performed, therapeutic no longer performed, therapeutic OGD/laparotomy for acute OGD/laparotomy for acute complicationscomplications

Strategies in Ulcer therapyStrategies in Ulcer therapy

Pre-HpPre-HpReduce acidReduce acid

Take antacidsTake antacids

SurgerySurgery

Post-HpPost-HpFind causeFind cause

Eliminate causeEliminate cause

Control symptoms in the meantimeControl symptoms in the meantime

Long-term therapy!!

H. Pylori TreatmentH. Pylori Treatment

Recurrence Rate/year inRecurrence Rate/year inHealed PUDHealed PUD

H.P(without Eradication) Anti-Ulcer Therapy H.P(without Eradication) Anti-Ulcer Therapy

H.P EradicationH.P Eradication

G.U G.U 59 % 25 % 59 % 25 % 4 % 4 %

D.UD.U 67 % 25 % 67 % 25 % 6 % 6 %

DysphagiaDysphagia Difficulty SwallowingDifficulty Swallowing TypesTypes

Mechanical obstructions ( Tumours / Stricture )Mechanical obstructions ( Tumours / Stricture ) Neuromuscular ( Stroke , Myasthenia Gravis )Neuromuscular ( Stroke , Myasthenia Gravis ) Motility & Functional obstructions ( Achalasis & Motility & Functional obstructions ( Achalasis &

DES )DES ) Common causesCommon causes

Young adults –Reflux strictures, AchalasiaYoung adults –Reflux strictures, Achalasia Older adults –Malignancy, Reflux stricturesOlder adults –Malignancy, Reflux strictures

Investigations CBC Gastroduedenoscopy vs. Barium Swallow CXR

Carcinoma of the Carcinoma of the OesophagusOesophagus

Common (Common (90% are malignant )90% are malignant ) Presents with dysphagia, weight loss, Presents with dysphagia, weight loss,

anaemia, anorexiaanaemia, anorexia Associated with male sex, alcohol, Associated with male sex, alcohol,

esophagitis, achalasia, smokingesophagitis, achalasia, smoking 8% of Barrett’s develop into 8% of Barrett’s develop into

adenocarcinomasadenocarcinomas 90% are squamous , 10% adenocarcinoma90% are squamous , 10% adenocarcinoma Diagnosed on Ba swallow/OGDDiagnosed on Ba swallow/OGD 5 year survival rate : 5 15 %5 year survival rate : 5 15 %

Esophageal carcinomaEsophageal carcinoma

Squamous cell carcinomaSquamous cell carcinoma More prevalent worldwideMore prevalent worldwide Risk factors: long-standing

esophagitis, achalasia, smoking, alcohol, diet (low vitamins and zinc), genetics

50% in middle 1/3

AdenocarcinomaAdenocarcinoma More common in More common in

USAUSA Occurs on top of Occurs on top of

Barrett esophagusBarrett esophagus More in distal 1/3More in distal 1/3

Achalasia: Clinical PearlsAchalasia: Clinical Pearls Majority present between 20 to 40 yearsMajority present between 20 to 40 years Solid and liquid dysphagia common >90%Solid and liquid dysphagia common >90% Regurgitation, weight loss, chest pain 40-60%Regurgitation, weight loss, chest pain 40-60% Barium Study: Accuracy ~95%Barium Study: Accuracy ~95% EndoscopyEndoscopy

Decreased Sensitivity (retained food)Decreased Sensitivity (retained food) Necessary to r/o pseudoachalasiaNecessary to r/o pseudoachalasia

More rapid onset of symptomsMore rapid onset of symptoms Late onset (age >60)Late onset (age >60) Difficult to pass scope through EGJDifficult to pass scope through EGJ

ManometryManometry Gold StandardGold Standard ↑↑LES tone, ↓LES relaxation, aperistalsis distal 2/3 LES tone, ↓LES relaxation, aperistalsis distal 2/3

esophagusesophagus

Achalasia: Clinical Pearls, Achalasia: Clinical Pearls, cont.cont.

TreatmentTreatment Medical (don’t usually work)Medical (don’t usually work)

NitratesNitrates CCBCCB

Botulinum toxinBotulinum toxin Pneumatic DilationPneumatic Dilation Surgical MyotomySurgical Myotomy Heller's Myotomy. Open or Heller's Myotomy. Open or

laparoscopiclaparoscopic

Diffuse Esophageal Spasm Diffuse Esophageal Spasm (DES)(DES)

Related Disorders of Esophageal HypermotilityRelated Disorders of Esophageal Hypermotility Barium StudyBarium Study

Corkscrew patternCorkscrew pattern ManometryManometry

>20% simultaneous nonperistaltic contractions (>30mmHg)>20% simultaneous nonperistaltic contractions (>30mmHg) Potential Therapeutic options (most ineffective)Potential Therapeutic options (most ineffective)

Medical (Medical (TCAsTCAs, Nitrates, CCBs), Nitrates, CCBs) DilationDilation Botox InjectionBotox Injection

ODYNOPHAGIAODYNOPHAGIA

Painful SwallowingPainful Swallowing CAUSES OF ODYNOPHAGIACAUSES OF ODYNOPHAGIA

1- Drug Induced Esophagitis:1- Drug Induced Esophagitis:

2-Infectious Esophagitis :2-Infectious Esophagitis : Candidia Candidia /HSV /CMV./HSV /CMV.

3- Corrosive Esophagitis .3- Corrosive Esophagitis .

4- Severe Reflux Esophagitis4- Severe Reflux Esophagitis

Drugs-Induced Drugs-Induced EsophagitisEsophagitis

Drug-Induced Esophagitis•ASA/NSAIDS•Doxycycline•FeSO4•Alendronate•potassium

Gastrointestinal Gastrointestinal DysfunctionDysfunction Nausea Nausea

A subjective experience that is associated with a number A subjective experience that is associated with a number of conditionsof conditions

The common symptoms of vomiting are hypersalivation The common symptoms of vomiting are hypersalivation and tachycardiaand tachycardia

AnorexiaAnorexia A lack of a desire to eat despite physiologic stimuli that A lack of a desire to eat despite physiologic stimuli that

would normally produce hungerwould normally produce hunger RetchingRetching

Nonproductive vomitingNonproductive vomiting

Vomiting Vomiting ( Neuromuscular reflex )( Neuromuscular reflex ) The forceful emptying of the stomach and intestinal The forceful emptying of the stomach and intestinal

contents through the mouthcontents through the mouth Several types of stimuli initiate the vomiting reflexSeveral types of stimuli initiate the vomiting reflex

Projectile vomitingProjectile vomiting Projectile vomiting is spontaneous vomiting that does not Projectile vomiting is spontaneous vomiting that does not

follow nausea or retchingfollow nausea or retching

Causes of Nausea and Causes of Nausea and VomitingVomiting

Peptic ulcer diseasePeptic ulcer disease Gastric outlet obstructionGastric outlet obstruction Intestinal obstructionIntestinal obstruction Acute gastritisAcute gastritis Acute cholecystitisAcute cholecystitis Acute pancreatitisAcute pancreatitis Acute hepatitisAcute hepatitis

HICCUPS (HICCOUGHS ) HICCUPS (HICCOUGHS ) CAUSESCAUSES

*Gastric Distention.*Gastric Distention.

*Sudden temperature changes.*Sudden temperature changes.

*C.N.S . Pathology.*C.N.S . Pathology. *Metabolic : *Metabolic : Uraemia /D.M / Hypocapnia Uraemia /D.M / Hypocapnia

/Electolytes/Electolytes imbalance /Toxic drugs &Alcoholimbalance /Toxic drugs &Alcohol..

*Vagus &Phrenic nerve irritation.*Vagus &Phrenic nerve irritation.

*Surgical :Anaesthesia *Surgical :Anaesthesia &postoperative.&postoperative.

*Psychogenic &Emotional stress*Psychogenic &Emotional stress..

ConstipationConstipation

Constipation is defined as infrequent Constipation is defined as infrequent or difficult defecationor difficult defecation

PathophysiologyPathophysiology Neurogenic disorders, functional or Neurogenic disorders, functional or

mechanical conditions, low-residue diet, mechanical conditions, low-residue diet, sedentary lifestyle, excessive use of sedentary lifestyle, excessive use of antacids, changes in bowel habitsantacids, changes in bowel habits**MedicationsMedications

opioidsopioidscalcium-channel blockerscalcium-channel blockersanticholinergicanticholinergic

**Decreased motilityDecreased motility

IleusIleus

**Mechanical obstructionMechanical obstruction

**Metabolic abnormalitiesMetabolic abnormalities

Spinal cord compressionSpinal cord compression

**DehydrationDehydration

**Autonomic dysfunctionAutonomic dysfunction

**MalignancMalignanc

DIARRHEADIARRHEA

It is a It is a Symptom or a Sign Symptom or a Sign NOTNOT a a DiseaseDisease

AS A SYMPTOMAS A SYMPTOM Frequency of bowel action Frequency of bowel action Looseness of stools Looseness of stools Increase in stool volumeIncrease in stool volume

AS A SIGNAS A SIGN Stools weight more than 240 gm/24 Stools weight more than 240 gm/24

hourshours

A A CombinationCombination

of theseof these

Abdominal PainAbdominal Pain Is a symptom of a number of Is a symptom of a number of

gastrointestinal disordersgastrointestinal disorders

Gastrointestinal bleedingGastrointestinal bleeding Upper gastrointestinal bleedingUpper gastrointestinal bleeding

Esophagus, stomach, or duodenumEsophagus, stomach, or duodenum Lower gastrointestinal bleedingLower gastrointestinal bleeding

Below the ligament of Treitz, or bleeding Below the ligament of Treitz, or bleeding from the jejunum, ileum, colon, or rectumfrom the jejunum, ileum, colon, or rectum

HematemesisHematemesis HematocheziaHematochezia MelenaMelena Occult bleeding ? MalignancyOccult bleeding ? Malignancy

Upper Gastrointestinal Upper Gastrointestinal BleedingBleeding

AcuteAcute (> 90% of cases) (> 90% of cases) NSAIDsNSAIDs Peptic ulcer diseasePeptic ulcer disease Erosive gastritisErosive gastritis Ruptured esophagogastric varicesRuptured esophagogastric varices Mallory-Weiss tearMallory-Weiss tear Erosive esophagitisErosive esophagitis

Upper GI BleedsUpper GI Bleeds

Young – PUD, congenital lesions, varicesYoung – PUD, congenital lesions, varices Old – Tumours, PUD, angiodysplasiaOld – Tumours, PUD, angiodysplasia Investigations –CBC, Fluid balance, Investigations –CBC, Fluid balance,

LFTs, clotting, OGD, angiography, cross LFTs, clotting, OGD, angiography, cross matchmatch

Minor bleeds – observe, monitor, Minor bleeds – observe, monitor, arrange OGDarrange OGD

Major bleeds – resuscitate, urgent OGD Major bleeds – resuscitate, urgent OGD (PPI given afterwards only), treat the (PPI given afterwards only), treat the causecause

Oesophageal BleedsOesophageal Bleeds

Reflux – small volumes, bright red, HxReflux – small volumes, bright red, Hx CA – scanty debris, rusty, other CA – scanty debris, rusty, other

symptomssymptoms Varices – sudden onset, painless, Varices – sudden onset, painless,

large volumes, darker, portal HT large volumes, darker, portal HT *treat with pressors**treat with pressors*

Mallory-Weiss – bright red, history of Mallory-Weiss – bright red, history of vomitingvomiting

Stomach BleedsStomach Bleeds

Gastritis – small volumes, bright, Gastritis – small volumes, bright, follows NSAIDS/alcohol/stressfollows NSAIDS/alcohol/stress

Ulcer – larger size, painless, herald Ulcer – larger size, painless, herald smaller bleeds, ? coffee groundssmaller bleeds, ? coffee grounds

CA – rare, small bleeds, suggestive CA – rare, small bleeds, suggestive historyhistory

Congenital lesions – spontaneous in Congenital lesions – spontaneous in young, otherwise well, moderate young, otherwise well, moderate bleedsbleeds

Duodenal BleedsDuodenal Bleeds

Ulcer – history, usually melaena Ulcer – history, usually melaena present, risk factors, coffee groundspresent, risk factors, coffee grounds

Aorto-enteric fistula – rare (except in Aorto-enteric fistula – rare (except in post-op AAA patients), fatalpost-op AAA patients), fatal

Rectal bleeding - Rectal bleeding - QuestionsQuestions

Duration of symptoms – yrs, monthsDuration of symptoms – yrs, months Previous episodes or treatmentPrevious episodes or treatment Is the blood:Is the blood:

mixed in with stoolmixed in with stool separate – found on toilet paper/splashes in toilet separate – found on toilet paper/splashes in toilet

bowlbowl Fresh or altered blood - ? Lower vs upper GI Fresh or altered blood - ? Lower vs upper GI

bleedbleedMain differentials :Main differentials : Haemorrhoids (piles)Haemorrhoids (piles) Colonic carcinomaColonic carcinoma Diverticular disease / bleeding ulcerDiverticular disease / bleeding ulcer Anal fissureAnal fissure Anal carcinoma (rare) Anal carcinoma (rare)

Lower Gastrointestinal Lower Gastrointestinal BleedingBleeding

AcuteAcute (> 90% of cases) (> 90% of cases) DiverticulosisDiverticulosis Ischemic colitisIschemic colitis AngiodysplasiaAngiodysplasia Colonic polypsColonic polyps CarcinomaCarcinoma HemorrhoidsHemorrhoids Radiation colitisRadiation colitis

Gastrointestinal BleedingGastrointestinal Bleeding

Gastric CarcinomaGastric Carcinoma Clinical features of all upper GI presentations Clinical features of all upper GI presentations

with post-prandial fullnesswith post-prandial fullness Male/Female 2:1,Male/Female 2:1, Predisposing factorsPredisposing factors – diet (fish, pickled – diet (fish, pickled

vegetables), atrophic gastritis, pernicious vegetables), atrophic gastritis, pernicious anaemia, previous gastric surgery, polyps, blood anaemia, previous gastric surgery, polyps, blood group Agroup A

InvestigationsInvestigations –CBC, LFT, OGD, Ba Meal, CT scan –CBC, LFT, OGD, Ba Meal, CT scan 5 year survival rate : 5% 5 year survival rate : 5%

Common sites of metastasis include peritoneum, spleen, pancreas, transverse colon

Treatment of Gastric CATreatment of Gastric CA

Most are not resectableMost are not resectable Poor response to combination Poor response to combination

chemotherapychemotherapy Palliative surgery – gastrectomy, Palliative surgery – gastrectomy,

gastrojejunostomygastrojejunostomy If resectable usually total gastrectomy If resectable usually total gastrectomy

and oesophagojejunostomy with node and oesophagojejunostomy with node clearanceclearance

EsophagoscopyEsophagoscopy

Indications and Indications and ContraindicationsContraindications

Indications include:Indications include: DysphagiaDysphagia RefluxReflux HematemesisHematemesis Atypical chest painAtypical chest pain Many other conditionsMany other conditions

Contraindications:Contraindications: To assess reflux symptoms that respond to To assess reflux symptoms that respond to

medical managementmedical management A uncomplicated sliding hiatal herniaA uncomplicated sliding hiatal hernia

ComplicationsComplications The minor ones:The minor ones:

Lacerations of the lips or tongueLacerations of the lips or tongue Dislodgment or fracture of teeth and possible Dislodgment or fracture of teeth and possible

aspirationaspiration Major complicationMajor complication

Esophageal perforationEsophageal perforation Cervical esophagus (40%)Cervical esophagus (40%) Mid esophagus (25%)Mid esophagus (25%) Distal esophagus (35%)Distal esophagus (35%)

Morbidity and mortality from perforation is Morbidity and mortality from perforation is directly related to the time interval between directly related to the time interval between the occurrence of injury, diagnosis and repairthe occurrence of injury, diagnosis and repair

MalabsorptionMalabsorption Mostly medical causesMostly medical causes Giardiasis ( Watery Diarrhoea )Giardiasis ( Watery Diarrhoea ) Coeliac disease – clasically diarrhoea, Coeliac disease – clasically diarrhoea,

steatorrhoea and weight loss, steatorrhoea and weight loss, although often vague symptomsalthough often vague symptoms

Whipples disease – fat malabsorption Whipples disease – fat malabsorption secondary to infection, presents with secondary to infection, presents with steatorrhoea, arthralgia and malaisesteatorrhoea, arthralgia and malaise

Radiation and ischaemic enteropathyRadiation and ischaemic enteropathy

Surgical CausesSurgical Causes Crohn’s diseaseCrohn’s disease Short bowel syndrome - <50cm functioning Short bowel syndrome - <50cm functioning

terminal ileum, global malabsorptionterminal ileum, global malabsorption B12 deficiency after terminal ileum B12 deficiency after terminal ileum

resectionresection Iron deficiency after gastrectomyIron deficiency after gastrectomy Blind loop bacterial overgrowth – exclusion Blind loop bacterial overgrowth – exclusion

of a loop of ileum (Crohn’s, post surgery, of a loop of ileum (Crohn’s, post surgery, fistula) with bacterial growth digesting fistula) with bacterial growth digesting nutrientsnutrients

Diagnosis of Infectious DiarrheaDiagnosis of Infectious Diarrhea History History WorkWork TravelTravel EatingEating Ill contactsIll contacts Recent antibioticsRecent antibiotics HIV or immunocompromisedHIV or immunocompromised Stool C&S, O&P (x1), fecal blood and leukocytes if Stool C&S, O&P (x1), fecal blood and leukocytes if

no improvement in 48 hours or severe disease with no improvement in 48 hours or severe disease with bloody stools, fever, dehydration : Consider bloody stools, fever, dehydration : Consider sigmoidoscopysigmoidoscopy

Liver Diseases Liver Diseases & &

DentistryDentistry

Liver : Normal physiologyLiver : Normal physiology

Secretion of bile for fat absorption Short term sugar storage (glycogen) Aged RBC breakdown and excretion

of bilirubin Synthesis of coagulation factors Synthesis of albumin Drug metabolism

ESLD:ESLD: (Regardless of Cause)

Loss of Synthetic function: Vit K dependant coagulation factors (II, VII,

IX, X) Hypoalbuminemia (edema)

Portal hypertension Esophageal, umbilical, hemorroidal varices Ascites (abdominal fluid build-up) Splenomegaly (thrombocytopenia)

Loss of de-toxification function: ammonia Encephalopathy

ESLD:ESLD: (Regardless of Cause)

Bone marrow toxicity: anemia, leukopenia and thrombocytopenia

Endocrine disturbances: testicular atrophy and

gynecomastia Esophagitis / gastritis

Elevated Liver enzymes: AST / ALT

ESLD:ESLD: (Regardless of Cause)

Elevated bilirubin: causing Jaundice

Elevated INR: causing bleeding

Decreased albumin: causing edema and ascites

Altered drug metabolism: unpredictable

Drug effect can be Up or Down

CHRONIC LIVER DISEASECHRONIC LIVER DISEASE (Any cause)(Any cause)

PORTAL HYPERTENSION HEPATOCELLULAR FAILURE PORTAL HYPERTENSION HEPATOCELLULAR FAILURE

HCC HCC **P.S.E. *JAUNDICE. P.S.E. *JAUNDICE.

*VARICES. *COAGULOPATHY.*VARICES. *COAGULOPATHY.*ASCITES.*ASCITES.*S.B.P*S.B.P*H.R.S*H.R.S

Etiology of Chronic Liver Diseases Etiology of Chronic Liver Diseases & Cirrhosis& Cirrhosis

Alcoholic liver diseaseAlcoholic liver disease Viral hepatitis Viral hepatitis Parasites (schistosomiasis)Parasites (schistosomiasis) Autoimmune Liver Diseases( Biliary disease )Autoimmune Liver Diseases( Biliary disease ) Primary hemochromatosisPrimary hemochromatosis

Cryptogenic cirrhosisCryptogenic cirrhosis Wilson’s, Wilson’s, 1AT def1AT def

Hepatic-Venous outflow obstructionHepatic-Venous outflow obstruction Toxicant and drugsToxicant and drugs Metabolic abnormalityMetabolic abnormality NASHNASH MalnutritionMalnutrition

Clinical ManifestationClinical Manifestation

Onset:Onset: Slowly ProgressiveSlowly Progressive

Majority: Majority: 3~53~5 years or years or 1010 yearsyears

Minority: Minority: 3~63~6 months months

Stages:Stages: CompensatedCompensated

DecompensatedDecompensated

Compensated StageCompensated Stage

FatigueFatigue Loss of appetiteLoss of appetite AnorexiaAnorexia Abdominal discomfortAbdominal discomfort Abdominal painAbdominal pain

Hepatomegaly (slightly or moderately)Hepatomegaly (slightly or moderately) SplenomegalySplenomegaly

Decompensated StageDecompensated Stage

Deterioration of Liver Deterioration of Liver FunctionFunction

Feature of Portal Feature of Portal HypertentionHypertention

Complications of Complications of CirrhosisCirrhosis Portal Portal

HypertensionHypertension Synthetic Synthetic

DysfunctionDysfunction CoagulopathyCoagulopathy EncephalopathyEncephalopathy

ImmunodeficiencImmunodeficiencyy

MalnutritionMalnutrition HCCHCC

79

XanthelasmaXanthelasma Scleral icterusScleral icterus JaundiceJaundice Fetor hepaticusFetor hepaticus Parotid hypertrophyParotid hypertrophy Spider angiomaSpider angioma GynecomastiaGynecomastia Ms wastingMs wasting Bleeding tendency Bleeding tendency

(bruising)(bruising) AnemiaAnemia Palmar erythemaPalmar erythema Dupuytern’s cont Dupuytern’s cont AstrexisAstrexis Ankle edemaAnkle edema

JaundiceJaundice

JaundiceJaundice

Jaundice is a yellowish discoloration of the Jaundice is a yellowish discoloration of the sclera, skin, mucus membranes, and body fluids sclera, skin, mucus membranes, and body fluids caused by the deposition of bile pigmentscaused by the deposition of bile pigments

It is usually caused by either an increased It is usually caused by either an increased production or decreased excretion of bilirubin production or decreased excretion of bilirubin from the bodyfrom the body

Jaundice can be classified into:Jaundice can be classified into: Prehepatic jaundice (increased production)Prehepatic jaundice (increased production) Hepatic jaundice (decreased excretion)Hepatic jaundice (decreased excretion) Post-hepatic jaundice (decreased excretion)Post-hepatic jaundice (decreased excretion)

Pre-HepaticPre-Hepatic Haemolytic anaemia – hereditary Haemolytic anaemia – hereditary

spherocytosis, sickle cell, spherocytosis, sickle cell, thalassaemia, Gilbert’s syndromethalassaemia, Gilbert’s syndrome

High levels of unconjugated High levels of unconjugated bilirubin, normal LFTs, raised bilirubin, normal LFTs, raised reticulocytesreticulocytes

Investigate further with blood film Investigate further with blood film and autoantibody screenand autoantibody screen

HepaticHepatic

Hepatic injury – viral hepatitis, Hepatic injury – viral hepatitis, sclerosis, cirrhosis, poisons, drugssclerosis, cirrhosis, poisons, drugs

Bilirubin tends to be conjugated, Bilirubin tends to be conjugated, (jaundice occurs out of failure to (jaundice occurs out of failure to excrete, not conjugate)excrete, not conjugate)

Abnormal LFTs (raised ALT/AST)Abnormal LFTs (raised ALT/AST) Investigate further with viral titres, Investigate further with viral titres,

USS, liver biopsyUSS, liver biopsy

Post-HepaticPost-Hepatic

WallWall LumenLumen Outside Outside LumenLumen

•Raised conjugated bilirubin (absorbed from biliary tree)

•Decreased urinary urobilinogen (bilirubin does not make it to the small bowel)

•Obstructed LFTs (raised ALP and GGT)

•Further investigation with USS, and then ERCP/CT as appropriate

JaundiceJaundice ↑↑Production: HaemolysisProduction: Haemolysis ↓↓UptakeUptake ↓↓Conjugation – Gilbert’s, Conjugation – Gilbert’s,

Crigler-NajjarCrigler-Najjar

Pre-Hepatic/ Unconjugated hyperbilirubinaemia

Hepatic /Mixed

Post Hepatic/ Conjugated hyperbilirubinaemia

Hepatocellular damage +/- cholestasis:Hepatocellular damage +/- cholestasis: Viruses: Hep A,B,C…CMV, EBVViruses: Hep A,B,C…CMV, EBV Alcoholic Hepatitis, Cirrhosis, metastasesAlcoholic Hepatitis, Cirrhosis, metastases Drugs – Paracetamol od, TB, Valproate, Drugs – Paracetamol od, TB, Valproate,

MAOIMAOI Obstruction of CBD:Obstruction of CBD: Gallstones, Ca Head Panc, LNGallstones, Ca Head Panc, LN Drugs: AbxDrugs: Abx Biliary cirrhosis, atresia, Biliary cirrhosis, atresia,

cholangitischolangitis Mirrizi’s SyndromeMirrizi’s Syndrome

ALT/AST

ALP

JaundiceJaundice

REVIEW CLASSIFICATION REVIEW CLASSIFICATION OF JAUNDICEOF JAUNDICE

PRE-HEPATICPRE-HEPATICheamolysisheamolysis

INTRA-HEPATICINTRA-HEPATIC

hepatitis, cirrhosis, hepatitis, cirrhosis, congenital congenital hyperbiliruniaemiahyperbiliruniaemia

POST-HEPATICPOST-HEPATIC

gallstones, tumours, gallstones, tumours, strictures, biliary atresiastrictures, biliary atresia

Unconjugated bilirubin

Conjugated bilirubin (water soluble)

Causes of HepatomegalyCauses of Hepatomegaly

Regular generalized enlargement without jaundiceRegular generalized enlargement without jaundice

Regular generalized enlargement with jaundiceRegular generalized enlargement with jaundice

Irregular generalized enlargement without jaundiceIrregular generalized enlargement without jaundice

Irregular generalized enlargement with jaundiceIrregular generalized enlargement with jaundice

Localized swellingsLocalized swellings

Manifestation of ESLDManifestation of ESLD

Manifestation of ESLDManifestation of ESLD

Spider Spider telangiectasias telangiectasias

Palmar erythema Palmar erythema Nail changes Nail changes Dupuytren's Dupuytren's

contracture contracture Gynecomastia Gynecomastia Testicular atrophy Testicular atrophy Hepatomegaly Hepatomegaly

Splenomegaly Splenomegaly Ascites Ascites Caput medusae Caput medusae Fetor hepaticus Fetor hepaticus Jaundice Jaundice AsterixisAsterixis

Symptoms of Advanced Symptoms of Advanced CirrhosisCirrhosis

Fatique, weaknessFatique, weakness Nausea, vomiting and Nausea, vomiting and

loss of appetiteloss of appetite Weight loss, muscle Weight loss, muscle

wastingwasting Jaundice, dark urineJaundice, dark urine Unusual bruisingUnusual bruising Spider naevi, caput Spider naevi, caput

MedusaeMedusae Bloody, black stools or Bloody, black stools or

unusually light-colored unusually light-colored stoolsstools

Vomiting of bloodVomiting of blood

Abdominal swellingAbdominal swelling Swollen feet or legs Swollen feet or legs Red palmsRed palms GynecomastiaGynecomastia Loss of sex driveLoss of sex drive Menstrual changes in Menstrual changes in

women women Generalized itchingGeneralized itching Sleep disturbances, Sleep disturbances,

confusion,desorientaticonfusion,desorientation,on,tremor, ataxia, tremor, ataxia, asterixisasterixis

Gynecomastia

Ascites

Caput Medusae

Umbilical hernia

Visible signs of advanced liver

cirrhosis

Complications of ESLDComplications of ESLD MalnutritionMalnutrition EncephalopathyEncephalopathy CoagulopathyCoagulopathy Portal HypertensionPortal Hypertension Variceal HemorrhageVariceal Hemorrhage

Pulmonary Pulmonary HypertensionHypertension {Hepatopulmonary {Hepatopulmonary syndrome}syndrome}

Hepatorenal Hepatorenal SyndromeSyndrome {HRS} {HRS}

Spontaneous Spontaneous Bacterial Bacterial PeritonitisPeritonitis {SBP} {SBP}

HyponatremiaHyponatremia

Signs of ESLDSigns of ESLD

Caput MedusaeCaput Medusae

Spider AngiomasSpider Angiomas

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Esophageal VaricesEsophageal Varices

Laboratory FindingsLaboratory Findings Aminotransferases Aminotransferases

-AST & ALT -AST & ALT Alkaline phosphatase Alkaline phosphatase Gamma-glutamyl Gamma-glutamyl

transpeptidase (GGT)transpeptidase (GGT) Bilirubin Bilirubin Albumin Albumin

Globulins Globulins Serum sodium Serum sodium Hematologic Hematologic

abnormalities abnormalities -- Anemia Anemia -Thrombocytopenia-Thrombocytopenia -Leukopenia-Leukopenia -Neutropenia-Neutropenia -Coagulation defects-Coagulation defects (PT & INR)(PT & INR)

PancreatitisPancreatitis Caused by gallstones and/or alcoholCaused by gallstones and/or alcohol Enzymatic spillage, inflammation, oedema Enzymatic spillage, inflammation, oedema

and necrosis of the pancreasand necrosis of the pancreas Presents with moderate upper abdominal Presents with moderate upper abdominal

pain radiating to back, nausea, vomiting, pain radiating to back, nausea, vomiting, pyrexia, tachycardia, paralytic ileus and pyrexia, tachycardia, paralytic ileus and occasionally retroperitoneal bleeding (Grey occasionally retroperitoneal bleeding (Grey Turner’s and Cullen’s signs)Turner’s and Cullen’s signs)

Confirm diagnosis with amylase >1000 (lab Confirm diagnosis with amylase >1000 (lab dependent)dependent)

ABG, CXR, ECG – these patients are often ABG, CXR, ECG – these patients are often very sickvery sick

ComplicationsComplications Acutely – abscess, sepsis, necrosis, Acutely – abscess, sepsis, necrosis,

ATN, haemorrhage, pseudocyst ATN, haemorrhage, pseudocyst formationformation

Chronic pancreatitisChronic pancreatitis

- CBD obstruction, diabetes, fibrosis, - CBD obstruction, diabetes, fibrosis, inflammation, steatorrhoeainflammation, steatorrhoea

- Surgical management (drainage of - Surgical management (drainage of dilated ducts) appropriate in a small dilated ducts) appropriate in a small minorityminority

Treatment of PancreatitisTreatment of Pancreatitis

IV fluids, analgesia, anti-emeticIV fluids, analgesia, anti-emetic Monitor observations, renal and Monitor observations, renal and

respiratory functionrespiratory function Analgesia Analgesia Evidence for ERCP if proven CBD Evidence for ERCP if proven CBD

stonestone Highly conservativeHighly conservative

Pancreatic NeoplasmsPancreatic Neoplasms Adenocarcinoma affecting any part of the pancreasAdenocarcinoma affecting any part of the pancreas Endocrine tumours cause a variety of syndromes Endocrine tumours cause a variety of syndromes

from secreted peptidesfrom secreted peptides M>F, more common after age 50M>F, more common after age 50 Predisposed to by smoking, diabetes, chronic Predisposed to by smoking, diabetes, chronic

pancreatitispancreatitis Symptoms and presentation dependent on siteSymptoms and presentation dependent on site

- Tail (15%) malignant ascites, anaemia, metastases - Tail (15%) malignant ascites, anaemia, metastases (peritoneal, liver)(peritoneal, liver)- Body (25%) back pain, anorexia, weight loss, - Body (25%) back pain, anorexia, weight loss, steatorrhoea, diabetessteatorrhoea, diabetes- Head (55%) painless progressive jaundice - Head (55%) painless progressive jaundice - Periampullary (5%) as above, occasionally with - Periampullary (5%) as above, occasionally with duodenal obstruction causing vomitingduodenal obstruction causing vomiting

Investigations and Investigations and PrognosisPrognosis

USS – biliary tree, occasionally visible USS – biliary tree, occasionally visible massmass

CT scan +/- biopsy or ERCP +/- CT scan +/- biopsy or ERCP +/- biopsy biopsy

90% of patients are dead within 12 90% of patients are dead within 12 months of diagnosismonths of diagnosis

Tissue type important (better Tissue type important (better prognosis for non-pancreatic peri-prognosis for non-pancreatic peri-ampullary tumour)ampullary tumour)

Management Management PalliationPalliation Coeliac nerve ablation (body tumours)Coeliac nerve ablation (body tumours) Enzyme supplements, insulinEnzyme supplements, insulin Relieve jaundice by ERCP Relieve jaundice by ERCP SurgerySurgery

CurativeCurative Rarely appropriateRarely appropriate Requires early presentation Requires early presentation Whipple’s pancreatico-duodenectomyWhipple’s pancreatico-duodenectomy