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SYMPTOMATOLOGY IN
GIT PART-11
DR.MUZAMIL JAMIL
ASSOCIATE PROFESSOR
MEDICINE
JAUNDICE
♦ Accumulation of bilirubin.
♦ Yellowish pigmentation of plasma.
♦ Discolouration of heavily perfused tissues

li...
♦ Jaundice manifestes even at lower levels in people

with fair skin and anemia
♦ Obscured in dark skin individuals or wit...
Production and metabolism
♦ Normal serum Bilirubin Conc.

5-17 micro mol/l
.3-1 mg/l
♦ More than 90% is unconjugated circu...
♦ 80% of Bilirubin –RBCs break down.
♦ 15-20%-Ineffective erythropoises and

metabolism of other heme containing
protiens
Metabolism
♦ Hepatic uptake.
♦ Conjugation.
♦ Excretion into bile.
Derangement of bilirubin
metabolism
♦ Over production .
♦ Decreased hepatic uptake.
♦ Decreased hepatic conjugation.
♦ Dec...
Pathological terms.
♦ Hemolytic.
♦ Hepatocellular.
♦ Obtructive.
Classification
♦ Predominantly unconjugated

1-Over production
A)Hemolysis
B)Ineffective erythropoises.
2-Decreased hepati...
♦ 3-Decreased conjugation.

(decreased glucoronyl transferase)
A)Hereditary
Transferase deficiency
.
Gilbert syndrome.
. C...
♦ Breast milk jaundice.
♦ Hepatocellular disease.
♦ 4-Sepsis.
Predominantly conjugated
hyperbilirubinema.
♦ 1.Impaired hepatic excreation

A.Familial or hereditary.
Dubin jhonson &Roto...
♦ 3)Alcohol

4)Sepsis
5)Post operative
6)Biliary
cirrhosis.
♦ Extrahepatic Biliary obstruction.
Intraductal
Compression of...
Evalution of jaundice.
Hyperbilirubinemia.
♦ Hemolysis—In direct Bilirubin.
♦ Hepatobiliary –Direct Bilirubin.
Unconjugated Hyperbilirubinia.
♦ Hemolysis.
♦ Resorbtion of large hematoma.
♦ Bil. Rarely above 5mg%.
♦ Gilbert syndrone i...
Conjugated Hyperbilirubinia
Hepatocellular.
Intrahepatic obstruction.
Extra hepatic obstruction.
Approach to patient with
jaundice.
♦ Age.

Young------- Hepatitis.
Old -------Malignancy.
♦ Duration of symptoms.
♦ Abdomi...
♦ Transfusion.(hepatitis B&C).
♦ Use of intravenous drugs.
♦ Sexual contact.
♦ Ethanol.
♦ Travel and immunization.
♦ Drugs...
♦ Sore throat and rash—

Infectious mononucleosis.
♦ Pruritis—Chronic cholestasis.
Hepatic: Primary Biliary cirrhosis.
.
S...
♦ Past history of jaundice, hepatitis,arthralgias

Prodromal symptoms.
Viral hepatitis.
♦ Previous surgery:Biliary procedu...
Physical examination.
♦ Excoriation.
♦ Fever and epigastric/RUQ tenderness.
♦ Painless jaundice.
♦ Enlarged tender liver.
...
♦ Peripheral stigmas of liver diasease.
♦ Wasting and lymphoadenopathy.
♦ History pointing to malignancy.

Primary tomours...
Diarrhea.
♦ Increase in daily stool weight of more than

250gm/24 hours.
♦ Normal bowel frequency ranges between
3times/da...
Factors influencing stool
weight ,consistency and
frequency. in diet.
♦ 1.fiber content
♦ 2.Gender.
♦ 3.Ingested medicines...
♦ Pseudodiarrhea:

Increased frequency with normal
weight.
IBS ,Proctitis and
Hyperthyroidism.
♦ Incontinence:
Involuntary...
Acute and choronic.
♦ Acute: 7---14 days.

occasionally less than 6 week.
♦ Chronic: More than 4 weeks.
Occasionally more ...
Epidemiology.
♦ In less than 5 years of age.

2—3 illnesses per child per
year.Developed countries.
10—
18 illnesses per c...
Acute infectious diarrhea.
♦ Non-inflammotry.
♦ Inflammotry.

.
NON-INFLAMMOTRY
♦ Watery.
♦ Non bloody.
♦ Periumblical cra...
Inflammatory diarrhea
♦ Fever.
♦ Bloody.
♦ Small in volume.
♦ Left lower quadrant cramps.
♦ Urgency and tenesmus.
Etiology(non-inflammatory)
♦ Viral:Norwalk,Nor walk like and Rota virus
♦ Protozoal: Giardia,cryptosporidium.
♦ Bactrial:
...
Food poisoning
♦ Staphylococcus aureus.
♦ Shortest incubation period.1—6 hours.

Lasts

for less than 12 houres.
♦ Infecte...
Bacillus cereus.
♦ Short incubation period.

1—6 hours emetic form.
Long
incubation period.
upto 18
hours diarrheal form.
...
Clostridium perferingens
♦ Incubation period 8—14 hours.
♦ Heat resistant spores.
♦ Inadequately cooked meat, poultry or

...
Etiology for infllammatory
diarrhea.
♦ Viral:CMV.
♦ Protozoal:Entamoeba histolytica.
♦ Bacterial:Shigella,salmonella,compy...
Approach to patient.
♦ HISTORY:

1.Duration.
2.Fever.Infections out side
the gut like malaria.
3.Frequency.May correlate
w...
♦ 5.Vomiting.

-Acute illness
-Toxin.
-Systemic disease.
-Obstruction.
♦ 6.Tenesmes:shigellosis.
♦ 7.Appearance of stools....
♦ -Rice watery—Vibrio cholera.

-Bulky white—small intestine.
♦ 8.Common source.
♦ 9.Antibiotic use.
♦ 10.Travel.
Physical examination.
♦ Signs of dehydration—Severity of illness.
♦ MILD.

-Thirst.
-Dry mouth.
-Decreased axillary sweat....
Moderate dehyderation.
♦ Orthostatic hypotension
♦ Skin tenting.
♦ Sunken eye balls.
Severe dehydration.
♦ Hypotension.
♦ Tachycardia.
♦ Confusion.
♦ Frank coma.
Prompt medical evaluation.
♦ Inflammatory diarrhea.
♦ High fever.
♦ Bloody diarrhea.
♦ Abdominal pain.
♦ 6 or more unforme...
Chronic diarrhea.
Diarrhea which persists for more than 4
weeks
Needs evaluation to exclude serious
pathology
Most of the ...
Classification.
♦ 1-Osmotic.
♦ 2-Secreatary.
♦ 3-Inflammatory.
♦ 4.Motility disorders.
♦ 5.Fectitious.
♦ 6.Malabsorptive c...
Osmotic diarrhea.
♦ Results from lack of absorption of orally

ingested solutes (food).Osmotic effect.
♦ Relieved with fas...
Steatorrheal causes.
♦ Intraluminal maldigestion.

.Chronic pancreatitis.
.Decreased bile salts.
.Bacterial over
growth.
♦...
Secreatary diarrhea.
♦ Excreation of large ammount more than

1 litre/day.
♦ No effect with fasting.
♦ Abnormal fluid and ...
Inflammatory diarrhea.
♦ Fever.
♦ Abdominal pain and tenderness.
♦ Hematochezia.
♦ Patients may have toxic looks.
♦ Extra ...
Motility disorders
♦ Systemic disorders like diabetes and

hyperthyroidism.
♦ Previous gut surgery.
♦ Irritable bowel.
♦ F...
Approach to patients.
♦ History.
♦ Symptoms and signs of inflammation.
♦ Extra intestinal manefestations.
♦ Perepheral ede...
♦ Systemic manifestations like flushing.
♦ Autonomic dysfunctions like postural drop

and disordered sweating in diabetes....
Common causes
♦ Abdominal tuberculosis.
♦ Coeliac disease.
♦ Inflammatory bowel disease.
♦ Giardiasis.
♦ Tropical sprue.
♦...
Symptomatology-GIT-1
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Transcript of "Symptomatology-GIT-1"

  1. 1. SYMPTOMATOLOGY IN GIT PART-11 DR.MUZAMIL JAMIL ASSOCIATE PROFESSOR MEDICINE
  2. 2. JAUNDICE ♦ Accumulation of bilirubin. ♦ Yellowish pigmentation of plasma. ♦ Discolouration of heavily perfused tissues likeskin,sclera and mucous membranes. ♦ Clinically hyperbilrubinemia manifests as icterus or jaundice. ♦ Serum bilrubin > 34-43 micro mol/l ♦ 2.6-2.5 mg/dl
  3. 3. ♦ Jaundice manifestes even at lower levels in people with fair skin and anemia ♦ Obscured in dark skin individuals or with edema. ♦ Need to be observed in sun light. ♦ Needs to be differentiated from Carotenemia charecterised by yellow brown pigmentation of palms ,soles and nasolabial folds with normal sclera ,mucosal membrane and urine color.
  4. 4. Production and metabolism ♦ Normal serum Bilirubin Conc. 5-17 micro mol/l .3-1 mg/l ♦ More than 90% is unconjugated circulating as albumin bound complex. ♦ Remainder conjugated(primarily glucuronide) to polar group which is water soluble and excreted in urine.
  5. 5. ♦ 80% of Bilirubin –RBCs break down. ♦ 15-20%-Ineffective erythropoises and metabolism of other heme containing protiens
  6. 6. Metabolism ♦ Hepatic uptake. ♦ Conjugation. ♦ Excretion into bile.
  7. 7. Derangement of bilirubin metabolism ♦ Over production . ♦ Decreased hepatic uptake. ♦ Decreased hepatic conjugation. ♦ Decreased excretion.
  8. 8. Pathological terms. ♦ Hemolytic. ♦ Hepatocellular. ♦ Obtructive.
  9. 9. Classification ♦ Predominantly unconjugated 1-Over production A)Hemolysis B)Ineffective erythropoises. 2-Decreased hepatic uptake. A)Prolonged fasting. B)Sepsis.
  10. 10. ♦ 3-Decreased conjugation. (decreased glucoronyl transferase) A)Hereditary Transferase deficiency . Gilbert syndrome. . Crigler Najjar syndrome. B)Neonatal jaundice. C)Acquired transferase deficiency Drugs inhibition –Choramphenical
  11. 11. ♦ Breast milk jaundice. ♦ Hepatocellular disease. ♦ 4-Sepsis.
  12. 12. Predominantly conjugated hyperbilirubinema. ♦ 1.Impaired hepatic excreation A.Familial or hereditary. Dubin jhonson &Rotor syndromes, Recurrent benign intrahepatic cholestasis, Cholestatic jaundice of pregnancy. B.Acquired disorders. 1)Hepatocellular diseases Hepatitis,cirrhosis. 2)Drugs. OCP, Androgens,Chloramphenical.
  13. 13. ♦ 3)Alcohol 4)Sepsis 5)Post operative 6)Biliary cirrhosis. ♦ Extrahepatic Biliary obstruction. Intraductal Compression of biliary duct. –
  14. 14. Evalution of jaundice. Hyperbilirubinemia. ♦ Hemolysis—In direct Bilirubin. ♦ Hepatobiliary –Direct Bilirubin.
  15. 15. Unconjugated Hyperbilirubinia. ♦ Hemolysis. ♦ Resorbtion of large hematoma. ♦ Bil. Rarely above 5mg%. ♦ Gilbert syndrone is an exception. ♦ Reticulocyte count is high. ♦ Hb is low. ♦ LDH is high.
  16. 16. Conjugated Hyperbilirubinia Hepatocellular. Intrahepatic obstruction. Extra hepatic obstruction.
  17. 17. Approach to patient with jaundice. ♦ Age. Young------- Hepatitis. Old -------Malignancy. ♦ Duration of symptoms. ♦ Abdominal pain. ♦ Fever and other symptoms of active inflammation. ♦ Appitite change,weight loss or altered bowels—Malignancy.
  18. 18. ♦ Transfusion.(hepatitis B&C). ♦ Use of intravenous drugs. ♦ Sexual contact. ♦ Ethanol. ♦ Travel and immunization. ♦ Drugs. Cholestsis.Anabolic steroids and chlorpromazine. Heepatocellular necrosis. Acetoaminophen,ATT.
  19. 19. ♦ Sore throat and rash— Infectious mononucleosis. ♦ Pruritis—Chronic cholestasis. Hepatic: Primary Biliary cirrhosis. . Sclerosing cholangitis. Extra hepatic obstruction. ♦ Acholic stools. ♦ Pregnancy.
  20. 20. ♦ Past history of jaundice, hepatitis,arthralgias Prodromal symptoms. Viral hepatitis. ♦ Previous surgery:Biliary procedures. . Stones,strictures. ♦ Pre existing IBD. ♦ Right heart failure. ♦ Skin tatooing. ♦ History of GI bleeding. ♦ Family history.Congenital spherocytosis.
  21. 21. Physical examination. ♦ Excoriation. ♦ Fever and epigastric/RUQ tenderness. ♦ Painless jaundice. ♦ Enlarged tender liver. ♦ Rapidly enlarging liver. ♦ Palpable gall bladder. ♦ Spleenomegaly.
  22. 22. ♦ Peripheral stigmas of liver diasease. ♦ Wasting and lymphoadenopathy. ♦ History pointing to malignancy. Primary tomours in abdomen ,breast and thyroid should be looked for.
  23. 23. Diarrhea. ♦ Increase in daily stool weight of more than 250gm/24 hours. ♦ Normal bowel frequency ranges between 3times/day to3times/week.
  24. 24. Factors influencing stool weight ,consistency and frequency. in diet. ♦ 1.fiber content ♦ 2.Gender. ♦ 3.Ingested medicines. ♦ 4.Exercise. ♦ 5.Stress.
  25. 25. ♦ Pseudodiarrhea: Increased frequency with normal weight. IBS ,Proctitis and Hyperthyroidism. ♦ Incontinence: Involuntary release of rectal contents.
  26. 26. Acute and choronic. ♦ Acute: 7---14 days. occasionally less than 6 week. ♦ Chronic: More than 4 weeks. Occasionally more than 6 weeks. ♦ Persistent:2—4 weeks. ♦ Acute infectious causes are commonest. ♦ Acute GI diseases are second only to URTI.
  27. 27. Epidemiology. ♦ In less than 5 years of age. 2—3 illnesses per child per year.Developed countries. 10— 18 illnesses per child per year in developing countries. One Billion cases world wide. 4—6 million deaths. 12600 Deaths/Day.
  28. 28. Acute infectious diarrhea. ♦ Non-inflammotry. ♦ Inflammotry. . NON-INFLAMMOTRY ♦ Watery. ♦ Non bloody. ♦ Periumblical cramps. ♦ Bloating. ♦ Nausea and vomitting . ♦ Single or in combition.
  29. 29. Inflammatory diarrhea ♦ Fever. ♦ Bloody. ♦ Small in volume. ♦ Left lower quadrant cramps. ♦ Urgency and tenesmus.
  30. 30. Etiology(non-inflammatory) ♦ Viral:Norwalk,Nor walk like and Rota virus ♦ Protozoal: Giardia,cryptosporidium. ♦ Bactrial: 1.Preformed toxins:Styphylococcus aures, bacellius cereus and clostridium perfringens 2.Enterotoxin production:Ecoli,vibrio cholera.
  31. 31. Food poisoning ♦ Staphylococcus aureus. ♦ Shortest incubation period.1—6 hours. Lasts for less than 12 houres. ♦ Infected human carriers are the source. ♦ If food is left to cool slowly and remains at room temperature organisms have opportunity to form toxins. ♦ Out breaks after picnics. ♦ Potatos,salads,mayonnise,cream pastries.
  32. 32. Bacillus cereus. ♦ Short incubation period. 1—6 hours emetic form. Long incubation period. upto 18 hours diarrheal form. ♦ If cooked rice is not refrigerated,heat resistant spores which have escaped boiling germinate and produce toxin.Frying before serving may not destroy these preformed heat stable toxins.
  33. 33. Clostridium perferingens ♦ Incubation period 8—14 hours. ♦ Heat resistant spores. ♦ Inadequately cooked meat, poultry or legumes. ♦ self limiting upto 24 hours.
  34. 34. Etiology for infllammatory diarrhea. ♦ Viral:CMV. ♦ Protozoal:Entamoeba histolytica. ♦ Bacterial:Shigella,salmonella,compylopacte r jejuni,entero invasive E-coli and vibrio parahemolytic.
  35. 35. Approach to patient. ♦ HISTORY: 1.Duration. 2.Fever.Infections out side the gut like malaria. 3.Frequency.May correlate with dehydration. 4.Abdominal pain. -Inflammatory nature. -RIF Pain with yersina. -Bloating with Giardiasis.
  36. 36. ♦ 5.Vomiting. -Acute illness -Toxin. -Systemic disease. -Obstruction. ♦ 6.Tenesmes:shigellosis. ♦ 7.Appearance of stools. -Blood—Shigellosis.
  37. 37. ♦ -Rice watery—Vibrio cholera. -Bulky white—small intestine. ♦ 8.Common source. ♦ 9.Antibiotic use. ♦ 10.Travel.
  38. 38. Physical examination. ♦ Signs of dehydration—Severity of illness. ♦ MILD. -Thirst. -Dry mouth. -Decreased axillary sweat. -Decreased urine out put. -Slight weight loss.
  39. 39. Moderate dehyderation. ♦ Orthostatic hypotension ♦ Skin tenting. ♦ Sunken eye balls.
  40. 40. Severe dehydration. ♦ Hypotension. ♦ Tachycardia. ♦ Confusion. ♦ Frank coma.
  41. 41. Prompt medical evaluation. ♦ Inflammatory diarrhea. ♦ High fever. ♦ Bloody diarrhea. ♦ Abdominal pain. ♦ 6 or more unformed stools/24 hours. ♦ Profuse watery diarrhea. ♦ Severe dehyderatuon. ♦ Elderly or immunocompromised patients.
  42. 42. Chronic diarrhea. Diarrhea which persists for more than 4 weeks Needs evaluation to exclude serious pathology Most of the causes are noninfectious.
  43. 43. Classification. ♦ 1-Osmotic. ♦ 2-Secreatary. ♦ 3-Inflammatory. ♦ 4.Motility disorders. ♦ 5.Fectitious. ♦ 6.Malabsorptive conditions. ♦ 7.chronic infections.
  44. 44. Osmotic diarrhea. ♦ Results from lack of absorption of orally ingested solutes (food).Osmotic effect. ♦ Relieved with fasting. ♦ Clinical symptoms are usually becauses of malabsorption of fat or carbohyderates. ♦ Osmotic causes include lactase deficiency, drugs like laxatives etc.
  45. 45. Steatorrheal causes. ♦ Intraluminal maldigestion. .Chronic pancreatitis. .Decreased bile salts. .Bacterial over growth. ♦ Mucosal malabsorption. .Celiiac disease. .Tropical sprue.
  46. 46. Secreatary diarrhea. ♦ Excreation of large ammount more than 1 litre/day. ♦ No effect with fasting. ♦ Abnormal fluid and electrolyte transport. ♦ Harmones mediated. ♦ Causes may include Carcinoid, Zollinger ellison syndrome, Medullary carcinoma of thyroid and extensive gut recsection.
  47. 47. Inflammatory diarrhea. ♦ Fever. ♦ Abdominal pain and tenderness. ♦ Hematochezia. ♦ Patients may have toxic looks. ♦ Extra intestinal manefestation may be present. ♦ Causes include IBD,malignancy,radiation enterits.
  48. 48. Motility disorders ♦ Systemic disorders like diabetes and hyperthyroidism. ♦ Previous gut surgery. ♦ Irritable bowel. ♦ Fecal impaction. ♦ Neurological disorders. ♦ FECTITIOUS DIARRHEA:Laxative abuse
  49. 49. Approach to patients. ♦ History. ♦ Symptoms and signs of inflammation. ♦ Extra intestinal manefestations. ♦ Perepheral edema or ascitis. ♦ Type of stools-intestinal malabsoption. ♦ Flatulence. ♦ Weight loss.
  50. 50. ♦ Systemic manifestations like flushing. ♦ Autonomic dysfunctions like postural drop and disordered sweating in diabetes. ♦ Diarrhea alternating with constipation-IBS. ♦ Effects of malabsorption like anemia, bleeding tendency,osteopenia,amenorrhea and infertility should be looked for.
  51. 51. Common causes ♦ Abdominal tuberculosis. ♦ Coeliac disease. ♦ Inflammatory bowel disease. ♦ Giardiasis. ♦ Tropical sprue. ♦ Colonic malignancy.
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