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Common gi problem for 4th year medical student
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  • 1. common GI problems for 4 th year medical student
    • Somchai Leelakusolvong, M.D.
    • GI Division, Dept of Medicine
  • 2. Common problems
    • Gastroesophageal Reflux Disease
    • Peptic ulcer disease
    • Upper GI hemorrhage
    • Dyspepsia
    • Acute d iarrhea
    • Chronic diarrhea
    • Constipation
    • IBS
    • Colonic cancer
    • Acute and chronic hepatitis
    • Steatohepatitis
    • Cirrhosis
    • Hepatocellular carcinoma
  • 3.
    • Acute Abdominal Pain
  • 4. Etiology of acute abdominal pain
  • 5. History taking for evaluation of patient with acute abdominal pain
    • 1. Location
    • 2. Onset
    • 3. Duration
    • 4. Character
    • 5. Radiation
    • 6. Aggravating factors
    • 7. Relief
    • 8. Accompanying symptoms
  • 6. Classification of pain by the rate of development
  • 7. Patterns of acute abdominal pain Subside spontaneously with time: gastroenteritis colicky progressive Abrupt:ruptured aneurysm
  • 8. 1 2 1 2 3 3 Visceral pain localization 1. midline epigastrium = foregut (T7-T9) 2. periumbilical region = midgut (T9-T11) 3. lower midabdomen = hindgut (T11-L1)
  • 9. Acute Abdominal pain
    • Acute epigastric / upper abdominal pain
      • Acute - moderate to severe
      • Chronic/Recurrent – mild to moderate (= dyspepsia )
    • Acute RUQ pain
      • with fever
      • without fever
  • 10. Acute Abdominal Pain
    • Acute epigastric / upper abdominal pain
      • Acute - Moderate to severe
      • Chronic/Recurrent – Mild to moderate (= dyspepsia ) 2. Acute RUQ abdominal pain
      • with fever
      • without fever
  • 11. Severe Acute (Epigastric) Upper Abdominal Pain
    • Biliary colic
    • Acute pancreatitis
    • PU perforation
    • Exacerbation of PU/NUD
    • Acute coronary syndrome
    • (Inferior wall myocardial ischemia)
    • Acute aortic dissection
  • 12. Severe Acute (Epigastric) Upper Abdominal Pain
    • Biliary colic
    • Acute pancreatitis
    • PU perforation
    • Exacerbation of PU/NUD
    • Acute coronary syndrome
    • (inferior wall myocardial ischemia)
    • Acute aortic dissection
  • 13. Biliary Pain (Colic)
    • Moderate to severe epigastric / RUQ pain with ‘specific’ characters
    • Due to gallstones or CBD stones
    • Biliary pain from CBD stones
      • pain not typical as biliary pain in GS
      • transient  AST / ALT (100-1000 IU/L)
  • 14. Biliary Pain (Colic) Severity of pain Time 30 min- 6 hr 15 min- 1 hr
    • Associated symptoms:
    • N-V
    • Radiation to back,
    • interscapular, Rt.shoulder
    • Sweating
  • 15. Severe Acute Epigastric Upper Abdominal Pain
    • Biliary colic
    • Acute pancreatitis
    • PU perforation
    • Exacerbation of PU/NUD
    • Acute coronary syndrome
    • (Inferior wall myocardia ischemia)
    • Acute aortic dissection
  • 16. Acute Pancreatitis
    • 1. Clinical
      • Acute moderate to severe abdominal pain anywhere in the abdomen (most common epigastrium and LUQ) in > 95% of cases
      • Pain radiates to back in ~50%
      • Mild abdominal distension and often  BS
    • 2. Investigation
      • Serum amylase or lipase > 3 times ULN
      • Plain abdomen
  • 17. Severe Acute (Epigastric) Upper Abdominal Pain
    • Biliary colic
    • Acute pancreatitis
    • PU perforation
    • Exacerbation of PU/NUD
    • Acute coronary syndrome
    • (Inferior wall)
    • Acute aortic dissection
  • 18. PU Perforation
    • Currently uncommon (? wide-space use of H 2 B and PPI)
    • Clues to the diagnosis
      • Hx of previous dyspepsia
      • Hx of NSAIDs or ASA (may not have dyspepsia)
      • Sudden onset of pain
      • Less vomiting
      • Guarding / rigidity (later)
    • Free air in plain abdomen *
  • 19. Exacerbation of PU / Functional Dyspepsia
    • Do not diagnose too often!
    • Usually not very severe
    • Other causes should be excluded before
    • Clues to the diagnosis
      • Hx of recurrent dyspepsia
      • Hx of NSAIDs or ASA
    • Gastroscopy should be warranted
  • 20. Severe Acute (Epigastric) Upper Abdominal Pain
    • Biliary colic
    • Acute pancreatitis
    • PU perforation
    • Exacerbation of PU/NUD
    • Acute coronary syndrome (Inferior wall)
    • Acute aortic dissection
  • 21. Epigastric Pain Mild, long duration or recurrent “ Dyspepsia” Acute-Severe Abdominal signs, Ileus? Loss liver dullness? Jaundice? CBC, amylase, AST/ALT, ALP, film abdomen series Amylase> 3 times Abnormal AST/ALT +/- ALP Free air Normal Acute pancreatitis Biliary colic PU perforation Bowel habit change? No Yes IBS, CA colon Rx as PU or Functional dyspepsia No response or recurrent Alarm feature? No Yes Gastroscopy Admit U/S Surgery
  • 22. Acute Abdominal pain
    • 1. Acute epigastric / upper abdominal pain
      • Acute - Moderate to severe
      • Chronic/Recurrent – Mild to moderate ( dyspepsia )
    • 2. Acute RUQ pain
      • with fever
      • without fever
  • 23. RUQ Pain Afebrile Febrile Hepatomegaly? Yes No Tender on percussion or point of tenderness? Yes No R/O liver abscess U/S Liver abscess Negative Systemic infection Jaundice No jaundice U/S U/S Ac.Cholangitis Ac.Cholecystitis Confirm Negative Confirm Biliary colic? Yes LFT, U/S No Hepatomegaly? Yes No U/S, LFT Liver abscess, HCC, other liver mass, hepatitis, congestion PU or NUD IBS, CA colon, Rt. UC
  • 24. Acute Calculous Cholecystitis
  • 25. Symptoms & Signs
    • Symptoms
    • 75 % have prior Hx of biliary colic
    • RUQ pain > 90 %
    • Fever 50 % , usually follows the pain
    • Signs
    • Fever 50 % : may be absent in elderly , gangrenous cholecystitis or empyema GB
    • Jaundice 20 % : mild jaundice
    • RUQ tenderness > 90 %
    • Murphy’s sign
  • 26. Murphy’s Sign  Sensitivity 65%, Specificity 87% Trowbridge RL, et al. JAMA 2003; 289: 80-86
  • 27. US Finding of Acute Cholecystitis
  • 28. Acute cholecystitis Admission, supportive care iv ATB 12-24 hr Determine surgical risk Low risk High risk Clinical Improvement Clinical Deterioration Clinical Improvement Clinical Deterioration Elective LC Within 72 hr Emergency LC Percutaneous Cholecystostomy D/C Non-surgical GS therapy Delayed elective LC 6-8 wk
  • 29. Acute Cholangitis
    • Etiology
    • 1. CBD obstruction
      • CBD stone
      • Benign stricture
      • Malignant obstruction
    • 2. Post CBD instrumentation
      • ERCP
      • Stenting
  • 30. Symptoms & Signs
    • 1. Fever 95 %
    • 2. RUQ tenderness 90 %
    • 3. Jaundice 80 %
    • 4. Confusion 15 %
    • 5. Hypotension 15 %
    • 1+2+3 = Charcot’s triad (20-70%)
    • 1+2+3+4+5 = Reynolds’ pentad
  • 31. Investigation
    • 1. CBC : leukocytosis, left shift in 80% of pts
    • 2. LFT : hyperbilirubinemia 80%, elevated AP
    • 3. Hemoculture: +ve in most cases
    • 4. Ultrasonography :
      • CBD stones : sensitivity 30-50%
      • Dilated CBD or IHD : sensitivity 75%, specificity 96%
    • 5. CT scan : better than US in detection of associated liver abscess and IHD stone
    • 6. MRCP
  • 32. Management
    • 1. Supportive Treatment
    • 2. Antibiotics : cover E.coli, Klebsiella spp and Enterococci
    • 3. Biliary drainage
      • 75-80 % will be improved after 12-24 hr of conservative Rx  Elective biliary drainage
      • 15-20 % will not be improved  Urgent biliary drainage
  • 33. Liver Abscess
    • Common liver abscess in clinical practice
        • Amoebic liver abscess (ALA)
        • Pyogenic liver abscess (PLA)
        • Meliodosis liver abscess (MLA)
  • 34. Symptoms & Signs of Liver Abscess NR 10 9 Ascites MLA PLA ALA 26 21-48 14-27 Jaundice 47 35-62 33-77 Abd tenderness NR 10 11 Peritonitis Signs 76 52-85 62-87 Hepatomegaly Hx dysentery RUQ pain Abd pain Fever Symptoms NR 0-11 10-42 24 45-48 47-60 44 52-58 86-100 100 42-86 51-84 Frequency (%)
  • 35. Systemic Infections
    • Can present with fever & RUQ pain
    • Clues
      • More systemic symptoms e.g. headache, myalgia
      • Multisystem involvement
      • May have no leukocytosis or even leukopenia
      • LFT may have hepatocellular picture
  • 36. RUQ Pain Afebrile Febrile Hepatomegaly? Yes No Tender on percussion or point of tenderness? Yes No R/O liver abscess U/S Liver abscess Negative Systemic infection Jaundice No jaundice U/S U/S Ac.Cholangitis Ac.Cholecystitis Confirm Negative Confirm Biliary colic? Yes LFT, U/S No Hepatomegaly? Yes No U/S, LFT Liver abscess, HCC, other liver mass, hepatitis, congestion PU or NUD IBS, CA colon, Rt. UC
  • 37.
    • Dyspepsia
  • 38. Dyspepsia-definition
    • Dyspepsia refers to pain or discomfort centered in the upper abdomen ( ปวดท้องเรื้อรังหรือเป็นๆ หายๆ หรือรู้สึกไม่สบายในบริเวณท้องส่วนบน )
  • 39. Prevalence of dyspepsia
    • The point prevalence of dyspepsia in general population is 20-25%
    • The annual incidence is 1.6-8%
    • Up to 5% of all consultations in primary care are for dyspepsia
    • Many patients with chronic dyspepsia never consult a physician
    Talley NJ. Am J Epiteniol 1992
  • 40. Prevalence of dyspepsia in general population 1 Knill-Jones 1991, 2 Talley 1996, 3 Penston 1996 4 Kang 1985, 5 Kachintorn 1999, 6 Katelaris 1992
  • 41. Etiology of dyspepsia (endoscopically) NUD 77% NUD 61.9% Misc 1.4% Misc 9.8% GU 11.1% GU 11.3% DU 8.2% DU 10.1% CA 2.1% CA 2.2% ESO 4.9% Stomach Research Group 1999 Siriraj Hospital 1997 N = 4222 N = 2926
  • 42. Community-based study of dyspepsia
    • District of Banpaeo, Central Region of Thailand
    • Populations = 94,564
    • 1,455 were randomly selected and interviewed for determination of dyspeptic symptoms
    Kachintorn U, et al.1999 The prevalence of dyspepsia is 65.98%
  • 43. A survey of etiology of dyspepsia and prevalence of H.pylori infection in every regions of Thailand Kachintorn U, et al.1999 n = 1,171 Overall H.pylori + 52.52%
  • 44. Causes of dyspepsia
    • 1. Functional dyspepsia (60%)
    • 2. Peptic ulcer (8-25%)
    • 3. Gastroesophageal reflux (3-15%)
    • 4. Gastric cancer (1-3%)
    • 5. Biliary tract diseases (10%)
  • 45. Clinical symptoms of dyspepsia
    • No difference between men and women
    • Prevalence of symptoms did not vary with age between 30-64 years
    • Gastroenterology 1992;102:1259-68
    • Clinical symptoms are unreliable for the diagnosis of the cause of dyspepsia
    • Gastroenterology 1993;105:1378-86
    • J Clin Gastroenterol 1993;161:149-54
    • BMJ 1989;298:30-2
  • 46. Dyspepsia NUD PUD or HBD PUD HBD Pain occurring before meal or when hungry Nocturnal epigastric pain Anemia … .of epigastric pain + + - - + - + -
  • 47.
    • 1999 Practice Guideline for the Management of
    • Dyspepsia in Thailand
    • by
    • The Stomach Research Group (SRG),
    • The Gastroenterological Association of Thailand (GAT)
  • 48. Dyspepsia R/O typical biliary pain, IBS Alarm features Life style modification (LSM) Education + symptomatic Antisecretory and/or prokinetic for 2-4 wks Consider appropriate Investigation Success continue till 6-8 wks No recurrence recurrence failure Alarm features Endoscopy + Ultrasound Approach to dyspeptic patient * At least 4 wks duration * uninvestigated
  • 49. Alarm features
    • 1. Age of onset > 40 years
    • 2. Awakening pain
    • 3. Significant weight loss ( > 5% BW within 1 month or > 10% within 3 months)
    • 4. History of GI bleeding
    • 5. Vomiting
    • 6. Dysphagia
    • 7. Strong family history of GI malignancy
  • 50. Alarm features
    • 8. Anemia
    • 9. Jaundice
    • 10. Hepatomegaly, splenomegaly, lymphadenopathy
    • 11. Fever
    • 12. Abdominal mass
    • 13. Abdominal distension
    • 14. Bowel habit change
  • 51. First-line management in uninvestigated patients Predominant pain or discomfort Predominant heartburn =GERD Ulcer-like Dysmotility-like + Dysmotility symptoms - Dysmotility symptoms Potent acid suppression Prokinetic Potent acid suppression + Hp eradication Investigate unresponsive patients
  • 52. Placebo response in functional dyspepsia
    • 30%-60%
    • This indicates that many patients will not required at all, and would be benefit most from general advice and reassurance
  • 53. Acid-reducing therapy
    • 14 studies of H 2 RA (Placebo-controlled) half show no benefit
    • half show statistically significant advantage over placebo
    • Subgroup of patients with reflux-like or ulcer-like symptom may benefit from acid reducing therapy
  • 54. Metoclopramide
    • Is a dopaminergic receptor blocker (crosses to blood-brain barrier)
    • Is superior to placebo in a double-blind trial
    • Similar as effective as domperidone
    • More CNS side effects (up to 20%)
  • 55. Domperidone
    • Mech: block dopaminergic receptor in the proximal gut
    • Action: Stimulate upper GI tract motility
    • : increase LES pressure
    • Effectiveness in functional dyspepsia
    • (14 studies)
    • 65-91% have good to excellent response significantly greater than placebo (13-42%)
  • 56. Cisapride
    • Mech: Enhance acetylcholine release from the postganglionic never endings in the myenteric plexus of GI tract
    • Action: Enhance motility along the entire GI tract
    • Effectiveness in functional dyspepsia
    • (14 studies)
    • 63-94% have good to excellent response significantly greater than placebo (6-56%)
  • 57. Cisapride in fucntional dyspspsia
    • > 140,000,000 patient treatments with cisapride since 1988
    • > 1400 patients included in clinical trials in FD
    • Meta-analysis
      • 8 placebo-controlled studies included
      • pooled results cisapride 36% >placebo
    Fimey et al. 1998
  • 58. Treatment of functional dyspepsia
    • Antispasmodic
    • Antiflatulant
    • Enzyme
    • Antianxiety
    • no scientific data to support their efficacy
  • 59. Dyspepsia R/O typical biliary pain, IBS Alarm features Life style modification (LSM) Education + symptomatic Antisecretory and/or prokinetic for 2-4 wks Consider appropriate Investigation Success continue till 6-8 wks No recurrence recurrence failure Alarm features Endoscopy + Ultrasound Approach to dyspeptic patient * At least 4 wks duration * uninvestigated
  • 60. Peptic ulcer disease (PUD)
  • 61. Gastric ulcer
  • 62. Pattern of pain of PUD
    • Stomach
      • visceral pain (mid epigastrium)
      • somatic pain (mid epigastrium, LUQ)
      • Peptic ulcer
      • chronicity, periodicity, daily rhythm
      • epigastrium, radiate to back
  • 63. Pathophysiological Relationships Underlying H.pylori Infection
    • Host predisposing factors
    • Smoking
    • Acid secretion
    • NSAID
    • Male
    • Age 30-50
    • Environmental factors
    • High salt
    • Low vitamin C
    • Nitrates
    • Acquisition at early life
    Infection with H.pylori Peptic ulcer CA
  • 64. Gastroduodenal Mucosal Integrity is Determined by Protective (“defensive”) and Damaging (“aggressive”) Factors HCO 2 Mucus Blood Flow Growth Factors Cell Renewal PGs Protective Damaging Hypoxia H + Pepsins Smoking Ethanol Bile acids Ischemia NSAIDs H.pylori
  • 65. Peptic Ulcers are Caused by Increased Aggressive Factors and/or decreased defensive factors Increased Aggressive Factors And/or Decreased Defensive Factors Mucosal Damage Ulcer
  • 66. Helicobacter pylori
  • 67.
    • PPI (RBC) standard dose bid +
    • Clarithromycin 500 mg bid (C) +
    • Amoxicillin 1000 mg bid (A) or
    • Metronidazole 500 mg bid (M)* for a minimum
    • of 7 days
    • *CA is preferred to CM as it may favor best results with second line PPI quadruple therapy
    The Maastricht 2-2000 First line therapy How to treat
  • 68. Which PPI in PPI triple therapy
    • There is no significant differences between each PPI
    • (i.e. omeprazole, lansoprazole, pantoprazole,rabeprazole and esomeprazole)
    • Eradication rate 85%-95%
    Van de Hurst RWM. Helicobacter 1996 Unge P. Eur J Gastroenterol Hepatol 1999
  • 69. การให้ยา anti-secretory ภายหลังการให้ยา กำจัดเชื้อ HP
    • โดยทั่วไปหลังรักษาด้วยการกำจัดเชื้อแล้ว ไม่มีความ จำเป็นต้องให้ยา anti-secretory ต่ออีก ยกเว้นกรณี เป็น complicated ulcer และมี comorbid condition ผู้ป่วยเหล่านี้ แนะนำให้ยา anti-secretory ต่อประมาณ 4-8 สัปดาห์
    1999 Thailand Consensus, SRG-GAT
  • 70. การติดตามผลการรักษา
    • ข้อบ่งชี้ว่ามีการกำจัดเชื้อ HP ได้คือการตรวจวินิจฉัยการติดเชื้อ HP ให้ผลลบเมื่อ 4 สัปดาห์หลังหยุดการรักษา โดยทั่วไปการติดตามผลการรักษาอาศัยการติดตามดูอาการเป็นสำคัญ ไม่มีความจำเป็นต้องส่องกล้องตรวจหรือตรวจยืนยันว่ากำจัดเชื้อได้แล้วซ้ำอีก ยกเว้น
    • 1. เป็น complicated ulcer เช่น มี bleeding หรือ previous perforation
    • 2. มี intractable pain หรือ recurrent symptom
    • 3. High risk gastric cancer ( กรณีนี้ต้อง biopsy ซ้ำเสมอ )
    • 4. Patient’s wishes
    1999 Thailand Consensus, SRG-GAT
  • 71. Goals of PU Treatment
    • Relieve symptoms
    • Heal ulcer
    • Prevent complication and recurrence
    • Cure disease
    Acid inhibition H.pylori eradication
  • 72. Evolving Management of PU Treat with single Anti-ulcer Test and Rx for Hp Treat with single Anti-ulcer 4-6 wks Symptoms remain Symptoms- free evaluate maintenance Confirm cure Obviates need for maintenance 8-12 wks Evaluate for healing DU GU healed maintenance
  • 73.
    • Constipation
  • 74. Definition of Constipation
    • < 3 times/week
    • strain excessively defecate
    • too hard or too small stools
    • a sense of incomplete evacuation
  • 75. The most common causes of constipation
    • Imaginary constipation
    • Bad bowel habits (ignoring the urge to defecate)
    • Poor diet (low fiber and water intake)
    • Laxative abuse
    • Medications
    • Irritable bowel syndrome
  • 76. Drugs Associated with Constipation (1)
    • Analgesics
    • Anticholinergics
    • Antispasmodics
    • Antidepressants
    • Anti-Parkinsonian drugs
    • Cation-containing agents
    • Iron supplements
    • Aluminum (antacids, sucralfate)
    • Calcium (antacids, supplements)
  • 77. Drugs Associated with Constipation (2)
    • Neurally active agents
    • Opiates
    • Antihypertensive
    • Ganglionic blockers
    • Vinca alkaloids
    • Anticonvulsants
    • Calcium channel blockers
  • 78. Clinical evaluation of constipation
    • Careful bowel history and PE
    • review of underlying illness
    • medications
    • diet
    • activity
    • other potential contributory factor
    • that many alter bowel habits
  • 79. Approach to constipation
    • Investigation is warranted if:
      • pain / straining
      • bloating
      • weight loss
      • anemia
      • recent change in bowel habit
      • hematochezia
  • 80. Threshold for persuing diagnostic testing depends on:
    • History and circumstances surrounding the constipation complaints
    • Patient’s age
    • Not responding to simple measures (fiber and water supplementation, temporary use of laxatives, an increase in physical activity)
    Minimum diagnostic evaluation: BE and sigmoidoscopy or colonoscopy Chronic idiopathic constipation Negative
  • 81. Chronic idiopathic constipation
    • Three subtypes:
    • 1. Colonic inertia
    • - almost exclusively in women and is of a painless variety
    • 2. Hindgut dysfunction
    • - increased nonperistaltic contraction of rectosigmoid segment
    • - mostly in young women with painful constipation
    • 3. Outlet obstruction
    • - produce symptoms of excessive straining at stool and sense of incomplete evacuation
    • - mostly in women
  • 82. Treatment of constipation
    • Prevention is the best treatment
    • Treat specific causes of constipation
  • 83. Management of constipation
    • Should be directed toward presumed pathophysiological mechanisms & psychological factors
    • consists of several strategies:
      • exercise & increased physical activity
      • dietary approached and increasing fluid intake
      • laxatives and enemas
      • surgery in special circumstances
  • 84. Treatment of constipation
    • First-line (combination of)
      • bowel training
      • dietary management
      • regular exercise
    • Second-line
      • bulk laxatives
      • osmotic laxatives (Milk of magnesia, PEG)
      • followed by other laxatives if needed
  • 85. Treatment of constipation
    • Third-line
      • psychological therapy
      • biofeedback
    • Fourth-line
      • surgery
      • (in case of intractable constipation)
  • 86. Dietary Approaches
    • High-fiber diet are often the initial intervention of most adults with constipation
    • Greatest help in those with low fiber intake and for patients with spastic constipation
  • 87. Bulk-forming laxative
    • Absorb water in the intestine and make the stool softer
    • are considered the safest laxative
    • can interfere with the absorption of drugs
    • should be taken with 8 ounces of water
  • 88. Stool softener
    • Provide moisture to the stool and prevent excessive dehydration
    • Recommended after childbirth or surgery
    • Docusate
  • 89. Lubricant laxative
    • Grease the stool and make it slip through the intestine more easily
    • Mineral oil
  • 90. Osmotic laxative
    • Cause water to secrete into colon
    • MOM, lactulose, epsom salt, PEG
  • 91. Stimulant laxative
    • Cause rhythmic contractions in the small and large intestine
    • Can lead to dependency
    • Can damage the bowel with prolonged daily use
    • Senna, phenolphthalein, bisacodyl, castor oil
  • 92. Algorithm for Treatment of Temporary Constipation Assess speed of action needed and longer term management Seek reason Effect within a week Lennard JE. Gastrointestinal Disease 1998:174 Effect within 2-3 D Effect within 24 hr Single or few doses Bulk laxative (Psyllium, ispaghula) Osmotic laxative (Mg, lactulose) Continued treatment Continued treatment Stimulant laxative (Senna, bisacodyl)
  • 93. Initial visit for chronic constipation Hx and PE Primary cause of constipation? Assess severity BE, sigmoidoscopy No mechanical obstruction Predominantly infrequency Redefine symptoms Predominantly straning Evaluate and treat Therapeutic trial of fiber Yes Mild Failure No Algorithm for Evaluation of Chronic Severe Constipation Severe Campion MC & Orr WC. Evolving Concepts in Gastrointestinal Motility 1996
  • 94. Acute Diarrhea
  • 95. Common causes of acute diarrhea
    • 1. Infections, e.g. bacteria, virus, parasite
    • 2. Food poisoning
    • 3. Drugs
    • 4. Fecal impaction
    • 5. Heavy metal poisoning
  • 96. History taking for acute diarrhea
    • 1. Stool appearance
    • - consistency, amount, bloody
    • 2. Associated symptom
    • - NV, fever, abdominal pain
    • 3. Details of food, milk
    • 4. Drugs
    • 5. Travel
    • 6. Systemic disease
  • 97. Drugs commonly associated with diarrhea
  • 98. PE for acute diarrhea
    • 1. Evaluation for fluid and electrolytes deficits
    • 2. Fever
    • 3. Abdominal signs
    • 4. PR
  • 99. Acute Diarrhea (<14 days) Toxin induced food poisoning or viral gastroenteritis
    • Symptomatic treatment
    • Replace deficit & maintain hydration with ORT/ORS/IVF
    Major Presentation Diarrhea predominant History & PE Vomiting predominant
  • 100. Maintain with ORT Diarrhea predominant
    • Replace rapidly
    • with ORS/IVF
    • Maintain with ORT
    • Stool exam, C/S
    Norfloxacine 400 mg bd x 3d Not improve
    • Consider sigmoidoscope
    • /colonoscopy + Biopsy
    Dehydration No Mild Moderate Severe Cure Not improve Not improve
    • Repeat stool exam
    • Ask for culture result
    • Change antibiotic
    +ve cholera Tetracycline 2 g/d x 3 d Appropriate antibiotic if pathogen identified Stool exam, C/S +ve E.hist trophozoites Metronidazole 500mg qid x 7d Watery Bloody
  • 101. Stool leukocyte
  • 102. Indication for sigmoidoscopy in patient with acute diarrhea and stool leukocyte positive
    • 1. Persistent diarrhea more than 7 days after treatment
    • 2. Suspicion of Amoebic colitis
    • 3. Suspicion of malignancy
    • 4. Antibiotic-associated diarrhea
    • 5. Suspicion of UC
  • 103. Indications for antibiotic treatment
    • 1. Invasive organism
    • 2. Decreasing the amount of organism to prevent transmission and to control the outbreak
  • 104. Recommended antibiotics in acute diarrhea Working party report, WCOG 2002 Fluoroquinolone: norfloaxacin 400 mg, ciprofloxacin 500 mg, b.i.d.
  • 105. Antidiarrheal drugs
    • Adsorbents
      • activated charcoal, kaolin, pectin, smectite, attapulgite, aluminum hydroxide, tannic acid
      • can increase stool consistency, decrease stool frequency but can not reduce fluid loss
    • Antiperistaltics
      • loperamide, diphenoxylate, codeine, tincture opium
      • reduced the frequency and volume of stool, contraindicated in invasive pathogens and in children and elderly people
  • 106.
    • Synthetic function
      • Albumin/globulin
      • Prothrombin time
      • Cholesterol
      • + BS
    • Excretory function
      • Bili (IB > 80-85%)
      • AP/GGT
      • Classic obstruction 3-5 times
    • Hepatocellular injury
      • SGOT/SGPT
    Abnormal Liver Function Test Half-life -SGOT 17 Hrs -SGPT 47 Hrs -AP 3 days - GGT 7-10 days In alcohol 28 days - DB 17-20 days - IB < 5 min
  • 107.
    • TB/DB(<2) SGOT(<40) SGPT(<45) ALB/GLO ALP(<117) GGT(<50)
    • CASE 1 5.4/4.3 1012 1566 3.1/3.5 128 96
    • CASE 2 2.1/1.5 1766 1655 3.9/2.9 280 700
    • CASE 3 6.8/3.6 78 69 3.8/3.2 135 88
    • CASE 4 12.3/8.5 336 180 3.0/3.8 158 335
    • CASE 5 3.4/0.5 125 55 4.1/2.9 89 45
    • CASE 6 0.9/0.2 56 62 3.9/2.9 92 30
    • CASE 7 0.7/0.2 48 47 3.9/2.8 555 300
    • CASE 8 15.6/9.8 78 88 3.5/3.0 402 250
    Abnormal Liver Function Test 1
  • 108.
    • TB/DB(<2) SGOT(<40) SGPT(<45) ALB/GLO ALP(<117) GGT(<50)
    • CASE 1 5.4/4.3 1012 1566 3.1/3.5 128 96
    Abnormal Liver Function Test 2
    • - hepatocellular jaundice(SGOT 10-40 เท่า , SGPT 10-40 เท่า , AP < 3 เท่า )
    • - DDx :
        • 1.Acute viral hepatitis
        • 2.Toxic hepatitis
        • 3.Ischemic hepatitis
        • 4.Drug induced hepatitis
  • 109. Patterns of Laboratory Tests in Types of Acute Hepatic Injury X-times : URI-upper reference limit
  • 110.
    • TB/DB(<2) SGOT(<40) SGPT(<45) ALB/GLO ALP(<117) GGT(<50)
    • CASE 2 2.1/1.5 1766 1655 3.9/2.9 280 700
    Abnormal Liver Function Test 3
      • DDx :
        • 1.Acute obstruction
        • 2.Drug induced hepatitis
        • 3.Toxic hepatitis
        • 4. Massive liver metastasis
      • hepatocellular damage with elevated out of proportion AP & GGT(SGOT & SGPT > 40, GGT >>>> AP)
  • 111.
    • TB/DB(<2) SGOT(<40) SGPT(<45) ALB/GLO ALP(<117) GGT(<50)
    • CASE 3 6.8/3.6 78 69 3.8/3.2 135 88
    Abnormal Liver Function Test 4
      • Intrahepatic cholestatic jaundice(TB & DB rising, nonspecific rising SGOT & SGPT)
      • DDx :
        • 1.Depend on specific conditions
        • 2.Systemic infection
        • 3.Drug induced hepatitis
  • 112.
    • TB/DB(<2) SGOT(<40) SGPT(<45) ALB/GLO ALP(<117) GGT(<50)
    • CASE 4 12.3/8.5 336 180 3.0/3.8 158 335
    Abnormal Liver Function Test 5
      • mild hepatocellular jaundice(SGOT >SGPT 2:1, nonspecific rising AP, rising GGT)
      • DDx :
        • 1.Alcoholic hepatitis (Hx:alcohol, SGOT < 8 เท่า , SGPT < 5 เท่า , GGT )
        • 2.Toxic hepatitis
        • 3.Drug induced hepatitis
  • 113.
    • TB/DB(<2) SGOT(<40) SGPT(<45) ALB/GLO ALP(<117) GGT(<50)
    • CASE 5 3.4/0.5 125 55 4.1/2.9 89 45
    Abnormal Liver Function Test 6
      • Indirect hyperbilirubinemia(IB > 80-85% of TB)
      • DDx :
        • 1.hemolysis
        • 2.Gilbert’s disease ( no other lab abnormal except Bili)
        • 3.renal impairment
        • 4.DRUGS( probenecid, rifabutin)
  • 114.
    • TB/DB(<2) SGOT(<40) SGPT(<45) ALB/GLO ALP(<117) GGT(<50)
    • CASE 6 0.9/0.2 56 62 3.9/2.9 92 30
    Abnormal Liver Function Test 7.1
      • nonspecific rising (SGOT & SGPT < 2 เท่า )
      • DDx :
        • 1.Nothing JUST OBSERVE
        • 2.Chronic vial hepatitis B or C
        • 3.NASH (SGPT > SGOT, SGPT < 4 เท่า )
        • 4.DRUGS or alcohol
        • 5.Autoimmune, Wilson’s disease, Hemochromatosis, Alpha1 antitrypsin deficiency
        • 6.Nonhepatic causes : Celiac sprue, muscle diseases ฯล
  • 115.
    • TB/DB(<2) SGOT(<40) SGPT(<45) ALB/GLO ALP(<117) GGT(<50)
    • CASE 6 0.9/0.2 112 136 3.9/2.9 92 30
    Abnormal Liver Function Test 7.2
      • Transminitis (SGOT & SGPT > 2 เท่า )
      • DDx :
        • 1.Nothing JUST OBSERVE
        • 2.Chronic vial hepatitis B or C
        • 3.NASH (SGPT > SGOT, SGPT < 4 เท่า )
        • 4.DRUGS or alcohol
        • 5.Autoimmune, Wilson’s disease, Hemochromatosis, Alpha1 antitrypsin deficiency
        • 6.Nonhepatic causes : Celiac sprue, muscle diseases ฯล
  • 116.
    • TB/DB(<2) SGOT(<40) SGPT(<45) ALB/GLO ALP(<117) GGT(<50)
    • CASE 7 0.7/0.2 48 47 3.9/2.8 555 300
    Abnormal Liver Function Test 8
      • elevated alkaline phosphatase & GGT
      • DDx :
        • 1.Infiltrative
        • 2.Space occupying lesion
        • 3.DRUGS
        • 4.???cholestasis
  • 117.
    • TB/DB(<2) SGOT(<40) SGPT(<45) ALB/GLO ALP(<117) GGT(<50)
    • CASE 8 15.6/9.8 78 88 3.5/3.0 402 250
    Abnormal Liver Function Test 9
      • Cholestatic jaundice(extrahepatic) or Chronic Obstructive jaundice (Bili < 25-30 mg%, AP ~ 3-5 เท่า , GGT ~ 12 เท่า , SGOT, SGPT เป็นแบบ nonspecific)
      • DDx :
        • 1.any causes of obstructive jaundice
  • 118. Abnormal Liver Function Test 10
    • สรุปว่า
        • ยา อยู่ทุกวงการ
        • SGOT & SGPT สูงมากๆ AVH, Shock, Toxic, Drugs
        • Out of proportion GGT & AP
          • GGT >>> AP Acute biliary tract obstruction
          • Drugs
          • Infection
        • AP , GGT ~ Bone disease ( AP < 2 เท่า )
        • GGT , AP ~ Alcohol
        • Mixed type of abnormal LFT