The document provides guidance on evaluating patients presenting with gastrointestinal (GI) diseases or symptoms. It outlines the following approach: 1. Take a thorough clinical history focusing on symptoms of pain, changes in bowel habits, nausea, etc. and their characteristics. 2. Perform a physical exam including inspection, palpation of the abdomen, digital rectal exam, and auscultation of bowel sounds. 3. Consider endoscopic procedures like sigmoidoscopy, upper endoscopy, or colonoscopy for direct visualization. Radiologic imaging like barium studies, ultrasound, CT and MRI can also help evaluate specific organs or abnormalities. 4. The diagnostic approach will depend on the presenting symptoms but may involve tests

1. APPROACH TO PATIENT WITH GI
DISEASE
DR. KOMBA

2. BIOLOGIC CONSIDERATIONS
• The spectrum of diseases affecting the GI tract and
their clinical manifestations are related to the
component organ(s) involved.
– Thus, esophageal disorders manifest themselves
mainly through their effects on swallowing
– gastric disorders are dominated by features
relating to acid secretion
– diseases of the small and large intestine
demonstrate disruption of nutrition and
alterations of bowel movements.

3. History
• A thorough clinical history is essential
• The most common complaints include
– Pain and
– Alterations in bowel habit, especially diarrhea or
constipation.

4. History
Abdominal pain
• is the most frequent and variable complaint
• may reflect a broad spectrum of problems, from self-limited
to urgent.
• intensity should be assessed
• an initial distinction should be made between pain of acute
onset and more chronic discomfort.
– Pain of abrupt onset more often reflects serious illness requiring
urgent intervention
– history of chronic discomfort is most often related to an indolent
disorder.

5. History
Abdominal pain---
• Dyspepsia, an ill-defined upper abdominal discomfort,
– often accompanied by nausea, bloating, and distention.
– may be a/w peptic ulceration, but non-ulcer dyspepsia
(NUD) is more common.
• A change in the pattern or character of pain may signify
disease progression.
• location of the pain (upper or lower, localized or diffuse)
• character (sharp, burning, cramping)

6. History
Abdominal pain---
• Relationship to meals
– Discomfort while pt. is eating- esophageal
disorder.
– Pain occurring shortly after meal may signify
biliary tract disease or abdominal angina
– pain 30 to 90 min later is typical of peptic disease.
– Pain that is not affected by eating - a process
outside bowel lumen - abscess, peritonitis,
pancreatitis, malignancies.

7. History
Abdominal pain---
• Relieving factors
– Eating or antacid use typically relieves pain in
peptic ulcer disease or gastritis.
• A relationship to bowel movement, esp. together
with an altered bowel habit, should focus attention
on a disorder of the small or large bowel, such as
IBD.

8. History
Alterations in bowel habit
• can result from either
– disruption of normal intestinal motility or
– significant structural pathology.
• The temporal evolution of the change, the nature of
the alteration, and the presence of other
constitutional symptoms such as weight loss, fever,
or anorexia are important.

9. History
Alterations in bowel habit---
• Temporary variation in bowel habit in a/w life stress
and in the absence of signs of systemic illness
suggests "irritable bowel syndrome,“
– alteration varies between diarrhea and constipation.
– Small, pellet-like stools associated with symptoms of
dyspepsia (bloating, nausea, and "gas") are common.
– This diagnosis can be made on the basis of history and PE
and very limited laboratory testing, to exclude structural
disease.

10. History
Alterations in bowel habit----
Constipation
• common complaint
• may reflect an obstructing process
• often due to impaired motility
– Though often functional in nature, drugs (e.g.,
anticholinergics), neurologic processes (e.g.,
Hirschsprung's disease), or smooth-muscle diseases (e.g.,
scleroderma) may cause decreased motility.
• Exclude hypothyroidism or depression

11. History
Alterations in bowel habit----
• Pain associated with constipation may suggest an
anal or perianal process with stool retention.
• Progressively worsening constipation and weight loss
in an adult with previously regular habits suggests
the possible presence of an underlying obstructing
process, particularly malignancy.

12. History
Alterations in bowel habit----
Diarrhoea
• Refers to an increased frequency of movements but
pts use the term to describe loose or watery stools.
– the daily average number of stools
– their consistency, their pattern, and
– the presence of blood
• Nocturnal or true bloody diarrhea almost always
reflects structural rather than functional bowel
disease.

13. History
• A pungent stool odor or presence of undigested
meat in the movement - pancreatic insufficiency.
• An alteration in color
– cholestasis or steatorrhea (light-colored)
– hemorrhage (melenic to maroon or bright red).
• Mucus - a sign of a functional bowel syndrome
• Pus - infectious or inflammatory disease
• Symptoms of acute GI bleeding, include
hematemesis, melena, and hematochezia

14. History
• Sexual hx esp in males with diarrhoea & dysphagia
– Homosexual males are at ↑risk for GI disorders
• History on present or past use of medications or
nonprescription drugs.
– Aspirin - occult blood found in the stool
– The use of daily laxatives - chronic diarrhea
• Thyroid and other metabolic disorders (affecting
calcium metabolism), can cause a variety of GI
symptoms.

15. Physical Examination, Endoscopy, and
Radiology
• Inspection may disclose signs of
– Cholestasis, nutritional deficiencies.
– mass (abd), draining fistula (Perianal)
• Palpation of the abdomen
– Tenderness and masses, which can lead to the recognition
of
• Cholecystitis, Crohn's disease
• Periappendiceal abscess and other disorders.
– Assessing liver and spleen size.
– Fluid thrill - ascites

16. Physical Examination, Endoscopy, and
Radiology
• Rebound tenderness, either direct or referred
– Localized or more generalized peritonitis, which
may suggest abdominal emergencies
• perforated viscus
• intraabdominal abscess
• bowel infarction
– The patient will remain immobile

17. Physical Examination, Endoscopy, and
Radiology
• In contrast, visceral disease e.g. intestinal ischemia
– Pts are mobile to find comfortable position
– absence of findings on palpation may be in
striking contrast to the evident distress of the
patient.
– till intestinal infarction and secondary peritonitis

18. Physical Examination, Endoscopy, and
Radiology
• Percussion
– Shifting dullness – ascites
• Auscultation may elicit
– a succussion splash (GOO).
– evolving ileus (absence of bowel sounds)
– an obstructing process (alteration in pitch)
– A bruit (ischemic bowel disease)

19. Physical Examination, Endoscopy, and
Radiology
• A digital rectal examination is also essential.
– the integrity of the sphincter
• In stool incontinence
– Masses intrinsic to the rectum
– abnormalities in the pelvis or the pouch of
Douglas
– The presence of frank or occult blood in the stool
is always important diagnostic information.

20. Physical Examination, Endoscopy, and
Radiology
• Endoscopy has supplanted conventional
contrast x-ray studies
–Because of its heightened precision for
diagnosis and
–The opportunity in many instances to
accomplish meaningful therapeutic
intervention.

21. • Sigmoidoscopy
• Upper GI endoscopy
• Endoscopic ultrasound (US)
• Colonoscopy

22. Physical Examination, Endoscopy, and
Radiology
• Endoscopic techniques limitations (continued
advantages of x-ray studies)
–Assessing GI motility (more accurately
assessed by barium studies).
– the small intestine inaccessible to
fiberoptic instruments
–Not available in every hospital
• use the upper GI series barium

23. Physical Examination, Endoscopy, and
Radiology
• Limitations of X-ray studies
– Should generally be avoided in patients with GI
bleeding or suspected bowel obstruction.
– The cathartics used to prepare the bowel may
markedly worsen the condition of a patient with
obstructing lesions or colitis.

24. Physical Examination, Endoscopy, and
Radiology
Other radiologic imaging modalities
• Have assumed a larger role in patients with GI
symptoms.
• US, CT, MRI
• Both US and CT are useful in the delineation of
abdominal masses.
• CT, though more expensive, is often more effective in
the evaluation of the lower abdomen
– inflammatory masses in pts with Crohn's disease
– complications of diverticular disease

25. Physical Examination, Endoscopy, and
Radiology
• US is an effective and less expensive tool for the
evaluation of the right upper quadrant, including the
gall bladder and biliary tract.
• MRI may give accurate information on the anatomic
extent of invasive rectal cancers and blood flow in
patients with vascular disorders
• More sophisticated CT and MRI equipment
–Digital angiography without the invasive
catheterization necessary in conventional angiography

26. Physical Examination, Endoscopy, and
Radiology
• CT "virtual colonoscopy,"
– A nonendoscopic method of visualizing the colon
• Radionuclide scans
– Can be used to localize a site of bleeding in the GI tract.
• Radiolabeled technetium
– Can detect a Meckel's diverticulum, which is an occasional
source of bleeding.

27. DIAGNOSTIC APPROACHES
Abdominal Pain
• Determining the cause is a clinical challenge
• Differential dx may encompass diseases extrinsic to the GI
tract, such as Genitourinary and peritoneal disorders
• First distinguish between an urgent problem and a nonacute
disorder.
• Hx, PE and lab tests e.g. stool exam will help
• Specific features will dictate urgent US or CT or prompt
surgery.
• In the pt with a long-standing and relatively stable problem,
diagnostic evaluation can be more deliberate.

28. DIAGNOSTIC APPROACHES
• A functional basis for the complaint may be
established on the strength of the hx and PE alone.
• Radiologic contrast studies / imaging modalities (e.g.,
US, CT), or endoscopic exam may be appropriate.
• If these approaches do not determine the cause of
the pt's symptoms, unusual causes of abdominal
pain such as acute intermittent porphyria may have
to be excluded through specific urine or blood tests

29. DIAGNOSTIC APPROACHES
Problems of Swallowing
• Dysphagia nearly always signifies the presence of
structural pathology.
• The approach should be as follows:
– Thorough determination of the nature of dysphagia
– Routine esophageal X-rays
– Esophagoscopy
– Manometric studies
– 24-Hour monitoring of esophageal pH

30. DIAGNOSTIC APPROACHES
Peptic or Digestive Disorders
The approaches to these disorders include the following:
1. Insertion of a nasogastric tube.
2. Upper gastrointestinal endoscopy
3. Gastric acid secretory studies.

31. DIAGNOSTIC APPROACHES
Obstructive and Vascular Disorders of the Small
Intestine
• careful history and physical examination
• The plain x-ray film of the abdomen
– Erect and decubitus views will show fluid levels in the
affected segments e.g. in volvulus or pancreatitis
– Air under the diaphragm - perforated viscus
– Air in the portal vein usually results from intestinal
necrosis from mesenteric vascular occlusion.

32. DIAGNOSTIC APPROACHES
Obstructive and Vascular Disorders of the Small
Intestine ----
• The diagnostic accuracy of the plain x-ray film in
intestinal obstruction is 75%.
• Vascular diseases of the small intestine are among
the most difficult diseases to diagnose.
• In chronic mesenteric ischemia, radiographic,
endoscopic, and laboratory tests are usually normal.
• Mesenteric angiography is essential to confirm the
diagnosis of vascular disease.

33. DIAGNOSTIC APPROACHES
Inflammatory and Neoplastic Diseases of Small and
Large Intestine
• History and physical examination
• Stool examination
– For exudate and blood
– Fresh stool samples for bacterial pathogens and parasites
• Sigmoidoscopy
– lesions of the rectum and distal colon.
• Colonoscopy
– the entire colon and terminal ileum (+biopsy and polyp
removal)

34. DIAGNOSTIC APPROACHES
Inflammatory and Neoplastic Diseases of Small and
Large Intestine
• The radiologic examination of the small intestine -
prestenotic and stenotic lesions of Crohn's disease.
• In colon, single barium enema examination in a well-
prepared patient has a diagnostic accuracy of 80-85%
• The addition of air-contrast technique brings the
accuracy up over 90%.
• Accuracy is greatly limited if the patient is poorly
prepared

35. DIAGNOSTIC APPROACHES
Malabsorption Syndromes
• History and physical examination
• Confirmed by examination of the stool
• Radiologic examination
– to rule out local lesions and to suggest motor and
secretory dysfunction
– rarely diagnostic unless an abnormal small-bowel
mucosa or fistulas between the intestine and
stomach are demonstrated.

36. DIAGNOSTIC APPROACHES
• Microscopic examination of a stool specimen stained with
Sudan is a simple screening test for steatorrhea.
• Chemical analysis of 3-day stool collection for fat, with the
patient on a standard diet, is used to establish the diagnosis of
steatorrhea.
• The D-xylose absorption test is about 90% accurate in
distinguishing mucosal disease from pancreatic insufficiency.
• Leakage of protein into the intestinal lumen can be
demonstrated by the recovery in stools of the serum protein
alfa1-antitrypsin or intravenously administrated markers such
as iodine- or chromium-labeled isotopes.

37. DIAGNOSTIC APPROACHES
GI Bleeding
• The history usually provides a reliable distinction
between lower and upper tract sources.
• Nasogastric tube is placed to confirm the site of
blood loss and to empty the stomach.
• Endoscopy is then performed to define the cause
and often to treat it.
• Sigmoidosopy may permit detection of distal sites of
bleeding.

38. DIAGNOSTIC APPROACHES
GI Bleeding
• Colonoscopy may also be of value
– Limited by active bleeding and poor prep
• Barium studies should be avoided in the acute
setting – nondiagnostic & interfere with angiography
• Radionuclide bleeding scan can locate the bleeding
site.