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  • 1. Manifestations of Gastrointestinal Diseases
    • Celso M. Fidel MD,FPSGS,FPCS
    • Diplomate Philippine Board of Surgery
  • 2. What are These Manifestations?
    • 1. PAIN
    • 2. FEVER
    • 3. ANOREXIA
    • 4. HEARTBURN and DYSPEPSIA
    • 5. DYSPHAGIA
    • 6. NAUSEA and VOMITING
    • 7. ABDOMINAL DISTENTION,
    • ERUCTATION and FLATULENCE
    • 8. CONSTIPATION
    • 9. DIARRHEA
  • 3. What are These Manifestations?
    • 10. ILEUS
    • 11. INTESTINAL OBSTRUCTION
    • a. Partial Obstruction and Pseudo-obstruction
    • b. Mechanical Obstruction
    • c. Closed Loop Obstruction
    • d. Colon Obstruction
    • 12. GASTROINTESTINAL BLEEDING
    • a. Upper GI Bleeding
    • b. Lower GI Bleeding
    • 13. JAUNDICE
  • 4.  
  • 5. I Pain
    • Most common symptom of GIT disease
    • Three kinds have been described in gen.
    • 1. Superficial or Cutaneous pain
    • 2. Deep pain from:
    • Muscles
    • Tendons
    • Joints
    • Fascia
    • 3. Visceral pain
  • 6. I Pain
    • Two Types of Pain
    • 1. Somatic Pain 2. Visceral Pain
    • Pathway:  A-delta fibers  Autonomic C-type fibers
    • Receptor:  Parietal, Muscle  Visceral
    • and Skin
    • Specific  Well localized  Poorly localized
    • Description  Sharp  Cramping, Gnawing
    • Stimulus:  Inflammation,  Distention, Traction
    • Pressure
  • 7. Pain
    • Un-referred Visceral Pain
    • ANS innervations:
    • bilateral hence pain is midline except:
    • Kidneys
    • Ureters
    • Cecum
    • Ascending colon
    • Descending colon
    • Sigmoid colon
  • 8. Pain
    • Un-referred Visceral Pain
    •  Midline location is the result of embryologic development of Gut
    •  Epigastric - Foregut:
    • Oropharynx
    • 2 nd portion of duodenum
    • Liver
    • Spleen
    • Pancreas
  • 9. Pain
    • Un-referred Visceral Pain
    •  Periumbilical- Midgut:
    • Distal duodenum
    • Jejunum
    • Ileum
    • Appendix
    • Ascending colon
    • Proximal transverse colon
    •  Hypogastric- Remainder of Hindgut= Colon
    • down to c loaca
  • 10. Pain
    •  REFERRED PAIN
    • Result of afferent neurons that innervate two entirely separate anatomically distinct structures that have a common embryologic
    • origin
  • 11. Pain
    •  REFERRED PAIN
    • 4 th Cervical Nerve Route
    • 1. Parietal peritoneum of the
    • diaphragm
    • 2. Area around the shoulder
    • 3. Supraclavicular hollow
    • e.g. Kehr sign = Pain underneath the diaphragm felt at the tip of the shoulder
  • 12. Pain
    •  REFERRED PAIN
    •  Thoracic Afferents T6-T8
    • Innervates :
    • 1. Right sub-scapular area
    • 2. Biliary tree
    • 3. Liver
    • 4. Peri-pancreatic area
  • 13. Pain
    •  REFERRED PAIN
    •  10 th Thoracic Nerve Route
    • Irritation to the kidney or ureter
    • e.g. In male= Flank and genital
    • pain classically testicular pain
    • In females this is referred to the
    • labia
  • 14. Acute Abdominal Pain
    • Clinical Manifestations
    • Sudden Onset =more likely surgical
    • Gradual Onset= inflammatory process
    • or slower progressive obstruction
    • Nausea and Vomiting 6-12 hours after
    • onset of pain=Obstruction lower GIT
  • 15. Acute Abdominal Pain
    • Clinical Manifestations
    • Foregut and Midgut inflammation
    • often followed by:
    • Anorexia
    • Nausea
    • vomiting
    • Sensory afferents carried by Vagal fibers
  • 16. Acute Abdominal Pain
    • Physical Examination
    • Inspection
    • Scaphoid = Normal
    • Distention= Abnormal
    • Thin Individuals= bowel loops seen
  • 17. Acute Abdominal Pain
    • Auscultation
    • Absent =No bowel sound in a minute
    • 1. Ileus
    • 2. Hypokalemia
    • 3. Peritonitis
    • 4. Hypomagnesemia
    • 5. Mesenteric thrombosis
    • 6. Narcotic Overdose
  • 18. Acute Abdominal Pain
    •  Auscultation
    • Hypoactive
    • 1. Hypokalemia
    • 2. Inflammation
    • 3. Ischemic bowel disease
  • 19. Acute Abdominal Pain
    • Auscultation
    •  Hyperactive
    • 1. Early small bowel obstruction
    • 2. Diverticulitis
    • Percussion
    • Palpation
  • 20. Acute Abdominal Pain
    • Laboratory Evaluation
    • CBC
    • Urinalysis
    • Blood Chemistry e.g. Amylase; Liver
    • function test
    • Pregnancy Test
    • ECG
  • 21. Acute Abdominal Pain
    •  Radiologic Examination
    • 1. Pneumoperitoneum
    • 2. Calculi
    • 3. Ileus
    • 4. Air fluid level
    • 5. Aerobilia
    • 6. Fat lines
  • 22. Acute Abdominal Pain
    • Ultrasound
    • 1. Suspected Pancreatic
    • 2. Hepatobiliary disease
    • 3. Phlegmon
    • 4. Abscess
    • 5. Pseudocyst
    • 6. Gynecologic Problem that mimics GIT
    • disease
  • 23. Acute Abdominal Pain
    •  Ultrasound
    • (F.A.S.T.) detecting Hemoperitoneum
    • in Blunt Trauma
    • 1. Sensitivity of 93.4%
    • 2. Specificity of 98.7%
    • 3. Accuracy of 97.5%
  • 24. Acute Abdominal Pain
    •  Surgical Decision Making
    • 1. Usually made by History
    • 2. Physical Examination is confirmatory
    • 3. Laboratory tests are focused on the
    • suspected diagnosis
  • 25. Acute Abdominal Pain
    • Nature of Surgical Decision Making in
    • Acute Abdomen does not require
    • specific diagnosis, but
    • 1. Plan of action
    • 2. Indication for the operation
    • 3. Timing and Approach
  • 26. Intermittent and Recurrent Abdominal Pain
    • 1. Various Hematologic disorders produce
    • abdominal pain
    • 2. Clinical Manifestations relate to the
    • occurrence of crisis; anemia; jaundice;
    • splenomegaly; and cholelithiasis
    • 3. Due to disturbed gastrointestinal motility
    • or alternating areas of spasm and
    • dilatation
  • 27. Chronic Abdominal Pain
    • If persistent-- is a clear pathophysiologic
    • abnormality such as:
    • 1. Chronic pancreatitis
    • 2. Pancreatic Malignancy
    • 3. Colonic Malignancy
    • May arise from the abdominal wall
    • 1. Iatrogenic peripheral nerve injuries
    • 2. Hernias
    • 3. Myofascial Pain Syndrome
  • 28. Intractable Abdominal Pain
    • 1. Challenging and sometimes a frustrating
    • problem
    • 2. Opiate Analgesics, if given in sufficient
    • dosage, usually can control abdominal
    • pain, however risk of addiction is always
    • there undermining patient’s ability to
    • function effectively
    • 3. In Properly selected patients, interruption
    • of pain pathway (Splanchnicectomy) is
    • suggested
  • 29. II FEVER
    • Not dangerous unless it is unusually high
    • Often a postoperative event often:
    • 1. A Thermostat reset
    • 2. Response to intraoperative body cooling
    • 3. Result of Normal Cytokine Activation
  • 30. II FEVER
    • Indication of Illness such as:
    • 1. Infection
    • 2. Inflammation
    • 3. Autoimmune Disease
    • 4. Neoplasia
    •  If persistent, indicative of infectious complication
  • 31. II FEVER
    • Pathophysiology
    • Inflammatory Response activates Cytokines
    • that are locally released in the brain or into
    • the bloodstream peripherally acting on the
    • hypothalamus in Endocrine fashion
  • 32. II FEVER
    •  Pathophysiology
    • Activated Macrophages also liberates pyrogens
    • 1. Interleukin
    • 2. TNF
    • 3. Interferon
    • Upward resetting of a thermoregulatory
    • Apparatus,triggering 2 physiologic mechanisms:
    • 1. Vasoconstriction
    • 2. Increase Heat production by shivering
  • 33. II FEVER
    • Clinical Manifestation
    • Those of GIT origin=Infection in the
    • Abdominal Cavity
    • Monomicrobial infections include:
    • 1. Biliary Tract Infection
    • 2. Spontaneous or Primary Peritonitis
  • 34. II FEVER
    • Clinical Manifestation
    • Intraabdominal Sepsis > polymicrobial
    • Fever of reactivated Crohn’s disease
    • Established Infection postop 10-20%
    • 20% of unknown origin 2ndary to CA.
  • 35. III Anorexia
    • Complicates many diseases
    • Indicates a significant degree of
    • inflammation
    • Common in liver disease, through CNS
    • mechanism, probably mediated at least
    • in part by Ammonia & Neuropeptide Y.
  • 36. III Anorexia
    • Common cause is Carcinoma, usually
    • with significant tumor burden
    • Postoperatively associated with loss of
    • taste, especially in diarrhea whose zinc
    • stores are chronically low. Give 220 mgs
    • daily and taste returns in 10 days to 3 weeks.
  • 37. III Anorexia
    • Pathophysiology
    • Complex and Multifaceted. In Animals
    • independent variables alter food intake:
    • 1. Changes in glucose utilization rate
    • 2. Changes in rate of lipid metabolism
    • 3. Alteration in brain & peripheral peptides.
    • 4. Imbalance in plasma & brain amino profiles
    • 5. Increase & decrease neurotransmitter activity
    • 6. Alteration in Cytokine levels
  • 38. III Anorexia
    • Pathophysiology
    • Hypothalamus is feeding center of the brain
    • Lateral area lesions = anorexia
    • Ventro-medial region lesions causes
    • hyperphagia and obesity
    • Vagal afferents , important in communicating
    • peripheral nutrition related information from
    • the GIT or from Glucose sensitive cells in the
    • liver
  • 39. III Anorexia
    • Pathophysiology
    • Galanin located in several brain regions appear to selectively stimulate fat intake
    • According to Glucostatic hypothesis of feeding,
    • increased use of glucose signal satiety, and
    • decreased glucose metabolism is associated
    • with hunger
  • 40. III Anorexia
    • Pathophysiology
    • The discovery of obese gene protein( leptin)
    • provides a proposed mechanism for modula-
    • tion of food intake and body weight that is
    • directly related to adipose tissue mass. Level
    • of circulating leptin increase as the amount
    • of adipose tissue increases
  • 41. III Anorexia
    • Pathophysiology
    • Elevated activity in Serotonin neurons
    • also inhibit feeding; reducing serotonin
    • levels usually increases the amount of
    • feeding elicited by orexigenic agents
  • 42. III Anorexia
    • Pathophysiology
    • Carbohydrate intake appears to be under
    • Neuropeptide Y control
    • Adrenalectomy reduces feeding elicited
    • by intrahypothalamic Neuropeptide Y
    • or nor epinephrine
  • 43. III Anorexia
    • CANCER Anorexia
    • Results from tumor-induced aberrations
    • of neurochemical mechanisms that
    • normally control hunger and satiety
    • Weight loss & Cachexia have significant
    • negative prognostic implications
  • 44. III Anorexia
    • CANCER Anorexia
    • Weight loss of 10-15 % during 3 to 4
    • months is one of two prime indicators
    • that a patient may be nutritionally or
    • immunologically impaired
  • 45. IV HEARTBURN AND DYSPEPSIA
    • Substernal burning associated w/ bitter taste
    • Normal individuals experience this when lying
    • down or bending over after overeating &
    • gastric capacity is exceeded
  • 46. IV HEARTBURN AND DYSPEPSIA
    • Esophagus is normally protected by:
    • 1. Competent Lower esophageal sphincter
    • 2. Rapid Esophageal clearing of reflux material
    • 3. Neutralization of refluxed acid by bicarbonate
    • rich saliva
    • 4. Intact mucosal diffusion barrier
    • Most common clinical abnormality of
    • esophageal motility is incompetence of LES
  • 47. IV HEARTBURN AND DYSPEPSIA
    • Dyspepsia is a non specific term given
    • to a collection of symptoms involving:
    • 1. Esophagus
    • 2. Stomach
    • 3. Duodenum
    • 4. Biliary Tree
    • 5. Pancreas
  • 48. IV HEARTBURN AND DYSPEPSIA
    • It is a postprandial complaint involving:
    • 1. Substernal pressure
    • 2. Epigastric distress
    • 3. Nausea
    • 4. Bloating
    • Three (3%) of these patients have angina
  • 49. IV HEARTBURN AND DYSPEPSIA
    • Work-up should include:
    • 1. Cineflouroscopy
    • 2. Contrast Radiography
    • 3. Upper GI series
    • 4. Endoscopy and Biopsy
  • 50. IV HEARTBURN AND DYSPEPSIA
    • Manometry if esophageal spasm is
    • suspected
    • Relationship of symptoms to eating and
    • other activities may give clues to the
    • diagnosis
  • 51. V DYSPHAGIA
    • Disturbances in swallowing can be
    • categorized according to the etiologies:
    • 1. Degenerative
    • 2. Functional
    • 3. Inflammatory
    • 4. Mechanical
    • 5. Autoimmune
    • 6. Neoplastic
    • Odynophagia= Painful swallowing
  • 52. VI NAUSEA AND VOMITING
    • 1. May be related or unrelated to diseases
    • of the gastrointestinal tract
    • 2. Vomiting may result whenever any part
    • of the GIT excessively irritated, over-
    • distended, or excitable
    • 3. Duodenal distention is a particularly
    • potent stimulus for vomiting
    • 4. Vagal and Sympathetic afferents carry
    • impulses from the GIT to the bilateral
    • vomiting center in the medulla
  • 53. VI NAUSEA AND VOMITING
    • Rapidly changing directions of motion
    • stimulate receptors in the labyrinthine
    • apparatus, impulses are carried into the
    • vestibular nuclei into the cerebellum to
    • vomiting center
  • 54. VI NAUSEA AND VOMITING
    • Ischemia to the vomiting center in:
    • 1. Increased intracranial pressure
    • 2. Anemia
    • 3. Vascular occlusion
    • 4. Shock
    • 5. Severe pain
  • 55. VI NAUSEA AND VOMITING
    • A variety of antibiotics directly affecting
    • the GIT may cause nausea & vomiting:
    • 1. Erythromycin
    • 2. Bactrim
    • 3. Neomycin
  • 56. VI NAUSEA AND VOMITING
    • Acute Nausea and Vomiting due to:
    • 1. Inflammation or infectious agents
    • affecting the GIT
    • 2. Neoplastic disease
    • 3. Mechanical obstruction at any level
  • 57. VII ABDOMINAL DISTENTION,ERUCTATION AND FLATULENCE
    • Most of these patient’s are Aerophagics;
    • they swallow too much Air when they
    • eat too quickly or talk too much when
    • they eat. Hyperactive bowel sounds is
    • the rule.
  • 58. VII ABDOMINAL DISTENTION,ERUCTATION AND FLATULENCE
    • Chronic Eructation may be an indication
    • of chronic pathology
    • Lactase deficiency can result in Eructation
    • and Flatulence
  • 59.  
  • 60. VIII CONSTIPATION
    • Most often Mechanical in origin
    • In trauma with retroperitoneal hematoma
    • Can be a result of:
    • 1. Psychologic factor
    • Improper training
    • 2. Dietary constituents
    • 3. Laxatives & drugs
  • 61. VIII CONSTIPATION
    • Can be a result of:
    • 4. Neurogenic causes
    • a. Tabes Dorsalis
    • b. Multiple Sclerosis
    • c. Spinal Cord Tumor
    • 5. Decreased skeleto-muscular power
  • 62. IX DIARRHEA
    • Pathophysiological Mechanisms
    • 1. Luminal secretion of solute or water
    • 2. Exudation or the loss of protein, blood and
    • mucus
    • 3. Osmotic retention of water
    • 4. Abnormal or disordered contact between
    • chyme and the absorptive surface of bowel
    • History is important in ascertaining whether
    • this is new, chronic, or recurrent problem
  • 63. X ILEUS
    • Three Types
    • 1. Adynamic or inhibition ileus
    • a. Most Common
    • b. Inhibition of normal neuromuscular activity
    • 2. Spastic Ileus with a tightly contracted bowel
    • without propulsive activity
    • 3. Ischemic Ileus from either low flow( non-
    • occlusive ischemia) or vascular occlusion
    • Coordinated motility is impossible because
    • of dying musculature
  • 64. X ILEUS
    • Adynamic ileus occurs after a variety of
    • abdominal operations
    • 1. Gastric ileus last approximately 2 days
    • 2. Colonic ileus last for approximately 3-4 days
    • 3. In the normal postoperative course, the small
    • bowel continues to function
  • 65. X ILEUS
    • If ileus is prolonged possible causes includes:
    • 1. Metabolic
    • 2. septic
    • 3. Mechanical or inflammatory
  • 66. XI INTESTINAL OBSTRUCTION
    • Classification
    • 1. Extra luminal( including adhesions and
    • Neoplastic Disease
    • 2. Intra luminal( such as gallstone ileus & stricture
    • 3. Intra mural( such as crohn’s disease
    • Small bowel obstruction secondary to adhesion
    • constitutes 60-80%
    • Hernia constitutes 15-20%
    • Colonic Obstruction due to CA is 60%
  • 67. XI INTESTINAL OBSTRUCTION
    • Partial Obstruction and Pseudo-obstruction
    • Chronic Nausea and Vomiting
    • When intestinal, bowel sounds reflect amphoric
    • fluid filled bowel loops
    • Succussion spasm when pylorus & duodenum
    • are obstructed
  • 68. XI INTESTINAL OBSTRUCTION
    • Partial Obstruction and Pseudo-obstruction
    • Chronic intestinal pseudo-obstruction involves
    • abnormalities in:
    • Intestinal muscle( myopathic)
    • Nervous system( myenteric) e.g. Chagas’
    • disease and infiltrative diseases
  • 69. XI INTESTINAL OBSTRUCTION
    • Partial Obstruction and Pseudo-obstruction
    • 1. Pseudo-obstruction postop is most dangerous
    • Vagotomized patients
    • Intestinal Operation
    • 2. Early recognition of Pseudo-obstruction is
    • critical to proper therapy
    • a. Biopsy of intestine may or may not reveal
    • loss of myenteric plexi
    • b. Full thickness rectal biopsy( Hirschsprung’s
    • Disease) is suspected
  • 70. XI INTESTINAL OBSTRUCTION
    • Mechanical Obstruction
    • 1. Physiologic derangement if intact blood supply
    • a. Accumulation of fluid and Gas above the
    • point of obstruction
    • b. Altered bowel motility leading to systemic
    • derangement
    • 2. Gamble showed that mortality in simple type
    • was due to:
    • a. Loss of fluid and electrolytes by vomiting
    • b. Sequestration of fluid in obstructed bowel
  • 71. XI INTESTINAL OBSTRUCTION
    • Mechanical Obstruction
    • 3. After 48 hours, rate of entry of water into the
    • intestinal lumen increases as a consequence
    • of blood to lumen flux
    • 4. Prostaglandin release in response to bowel
    • distention, increases secretion to obstructed
    • loops
    • 5.Interference with the mesenteric blood supply
    • is the most serious complication of intestinal
    • obstruction
  • 72. XI INTESTINAL OBSTRUCTION
    • Close loop Obstruction
    • 1. Both afferent & efferent limbs are obstructed
    • 2. Rapid progression of strangulation of blood
    • supply before manifestations of obstruction
    • becomes obvious
    • 3. Abdominal distention does not occur
      
  • 73. XI INTESTINAL OBSTRUCTION
    • Colon Obstruction
    • 1. Fluid and Electrolyte sequestration progresses
    • more slowly
    • 2. Progressive distention is the most dangerous
    • aspect of non-strangulated colon obstruction
      
  • 74. XI INTESTINAL OBSTRUCTION
    • Clinical Manifestations
    • The distance of the obstruction from the ligament
    • of Treitz can be ascertained by:
    • 1. How long before vomiting takes place after
    • the onset of pain
    • 2. The nature of the vomitus
     
  • 75. XI INTESTINAL OBSTRUCTION
    • Clinical Manifestations
    • Cardinal Signs and Symptoms of Intestinal
    • Obstruction:
    • 1. Crampy Abdominal Pain
    • 2. Nausea & Vomiting
    • 3. Obstipation
    • 4. Abdominal Distention
     
  • 76. XII GASTROINTESTINAL BLEEDING
    • 1. Has high morbidity & mortality particularly in
    • the elderly
    • 2. Accurate diagnosis is critical before significant
    • amounts ( 4-6 units) of blood has been lost
    • 3. Bleeding represents the initial symptoms of
    • gastrointestinal disease in more than 1/3 of
    • patients & in 70% there is no history of
    • bleeding episode
  • 77. XII GASTROINTESTINAL BLEEDING
    • 4.Eighty( 80%) will stop spontaneously without
    • intervention
    • 5. Flexible endoscopy and arteriography play an
    • interesting role in the diagnostic & therapeutic
    • management
  • 78. XII GASTROINTESTINAL BLEEDING
    • Terminologies
    • 1. Hematemesis is vomiting of blood , either
    • digested in the stomach or fresh & unaltered
    • 2 . Melena is the per anal passage of stools
    • with altered blood that are black and tarry
    • 3. Hematochezia is the passage of liquid
    • blood or blood clots of varied brightness or
    • color, maroon to bright red
  • 79. XII GASTROINTESTINAL BLEEDING
    • Terminologies
    • As little as 50-60m l of blood produce melena
    • Melena can persist for 5-7 days after a 2-unit
    • (significant) bleed
    • Approximately 10 ml bleeding/ day (Guaiac +)
  • 80. XII GASTROINTESTINAL BLEEDING
    • Upper GI Bleeding
    • Bleeding above the ligament of Treitz
    • include:
    • 1. Esophagitis
    • 2. Esophageal Varices
    • 3. Gastritis
    • 4. Peptic Ulcer
    • 5. Mallory Weiss
    • 6. Gastric Carcinoma
    • 7. Hemobilia
  • 81. XII GASTROINTESTINAL BLEEDING
    • Upper GI Bleeding
    • 8. Stress Ulcer ( Documented Risk Factors)
    • a. Multiple System Trauma
    • b. Hypotension
    • c. Respiratory Failure
    • d. Sepsis
    • e. Jaundice
    • f . Burns
    • g. Renal Failure
    • h . Recent Surgery
  • 82. XII GASTROINTESTINAL BLEEDING
    • Lower GI Bleeding
    • Bleeding below the ligament of Treitz
    • includes:
    • 1. Diverticulitis
    • 2. Angiodysplasia
    • 3. Ulcerative Colitis
    • 4. Malignancy
  • 83. XII GASTROINTESTINAL BLEEDING
    • Lower GI Bleeding
    • Work-up
    • 1. Rectal Examination
    • 2. Proctosigmoidoscopy
    • 3.Technetium 99 scan (Tag RBC)
    • 4. Arteriography
    • 5. Barium Enema
  • 84. XIII JAUNDICE
    • GIT related Causes :
    • 1. Increased pigment production secondary to
    • tissue infarction
    • 2. Inflammatory disease; e.g. spontaneous
    • peritonitis
    • 3. Appendicitis, complicated by coliform organism
    • can give jaundice without pyelephlebiti
    • 4. Ampullary Carcinoma or Carcinoma of the
    • duodenum
  • 85.  
  • 86. THANK YOU!!!