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Approach to the Patient with Gastrointestinal Disease 1.pptx
- 1. Approach to thePatient with Gastrointestinal Disease
- 2. • Classification • Symptoms •Signs • Investigations
- 3. INTRODUCTION • GI diseasesdevelop as a result of abnormalities within or outside of the gut . • Range in severity from those that produce mild symptoms and no long-term morbidity to those with intractable symptoms or adverse outcomes. • May be localized to one organ or exhibit diffuse involvement at many sites.
- 4. Classification of GIDiseases • Impaired Digestion and Absorption • Altered Secretion • Altered Gut Transit • Immune Dysregulation • Impaired Gut Blood Flow
- 5. • Neoplastic Degeneration •Disorders Without Obvious Organic Abnormalities • Genetic Influences
- 6. Impaired Digestion andAbsorption • Most common intestinal maldigestion syndrome, lactase deficiency, produces gas and diarrhea after dairy products and has no adverse outcomes. • Celiac disease, bacterial overgrowth, infectious enteritis, Crohn's ileitis, and radiation damage, which affect digestion and/or absorption more diffusely, produce anemia, dehydration, electrolyte disorders, or malnutrition.
- 7. • Gastric hypersecretoryconditions such as Zollinger-Ellison syndrome damage the intestinal mucosa, impair pancreatic enzyme activation, and accelerate transit . • Biliary obstruction from stricture or neoplasm impairs fat digestion.
- 8. • Impaired pancreaticenzyme release in chronic pancreatitis or pancreatic cancer can lead to malnutrition.
- 9. Altered Secretion • Gastricacid hypersecretion occurs in Zollinger- Ellison syndrome, G cell hyperplasia, retained antrum syndrome. • Patients with atrophic gastritis or pernicious anemia release little or no gastric acid.
- 10. Altered Gut Transit •Impaired gut transit may be secondary to mechanical obstruction. • Esophageal occlusion often results from acid-induced stricture or neoplasm. • Gastric outlet obstruction develops from peptic ulcer disease or gastric cancer. • Small-intestinal obstruction results from adhesions , Crohn's disease, radiation- or drug-induced strictures.
- 11. • The mostcommon cause of colonic obstruction is colon cancer. • Achalasia is characterized by impaired esophageal body peristalsis and incomplete lower esophageal sphincter relaxation.
- 12. • Gastroparesis isthe symptomatic delay in gastric emptying of meals due to impaired gastric motility. • Intestinal pseudoobstruction causes marked delays in small-bowel transit due to enteric nerve or intestinal smooth-muscle injury. • Constipation also is produced by outlet abnormalities such as rectal prolapse, intussusception.
- 13. • Disorders ofrapid propulsion are less common. • Rapid gastric emptying occurs in postvagotomy dumping syndrome, with gastric hypersecretion. • Exaggerated intestinal or colonic motor patterns may be responsible for diarrhea in irritable bowel syndrome. • Accelerated transit with hyperdefecation is noted in hyperthyroidism.
- 14. Immune Dysregulation • Mucosalinflammation of celiac disease results from dietary ingestion of gluten-containing grains. • Eosinophilic esophagitis and eosinophilic gastroenteritis are inflammatory disorders with prominent mucosal eosinophils. • Ulcerative colitis and Crohn's disease are disorders of uncertain etiology that produce mucosal injury
- 15. Impaired Gut BloodFlow • Intestinal and colonic ischemia that are consequences of arterial embolus, arterial thrombosis, venous thrombosis, or hypoperfusion from dehydration, sepsis, hemorrhage, or reduced cardiac output.
- 16. Neoplastic Degeneration • Colorectalcancer & gastric cancer is most common and usually presents after age 50 years. • Esophageal cancer develops with chronic acid reflux • Anal cancers arise after prior anal infection or inflammation.
- 17. • Pancreatic andbiliary cancers elicit severe pain, weight loss, and jaundice and have poor prognoses. • Hepatocellular carcinoma usually arises in the setting of chronic viral hepatitis or cirrhosis secondary to other causes.
- 18. Disorders Without ObviousOrganic Abnormalities • No abnormalities on biochemical or structural testing . • Include irritable bowel syndrome, functional dyspepsia, functional chest pain, and functional heartburn. • These disorders exhibit altered gut motor function.
- 19. Genetic Influences • Inflammatorybowel disease & functional bowel disorders patients show a genetic predisposition.
- 20.
- 21. Symptoms of GastrointestinalDisease • Abdominal pain, heartburn, nausea and vomiting, altered bowel habits, GI bleeding, jaundice, dysphagia, anorexia, weight loss, fatigue.
- 22. Abdominal Pain • Visceralpain generally is midline in location and vague in character, while parietal pain is localized and precisely described.
- 23. Abdominal Pain causes •Appendicitis • Gallstone disease • Pancreatitis • Diverticulitis • Ulcer disease • Esophagitis
- 24. • GI obstruction •Inflammatory bowel disease • Functional bowel disorder • Vascular disease • Gynecologic causes • Renal stone
- 25. Nausea and Vomitingcauses • Medications • GI obstruction • Motor disorders • Functional bowel disorder • Enteric infection
- 26. • Pregnancy • Endocrinedisease • Motion sickness • Central nervous system disease
- 27. Diarrhea Large bowel diarrhoeaSmall bowel diarrhoea Presence of blood and mucous floating, greasy, containing undigested food particles Tenesmus present absent Small-volume Large-volume stools Hypogastric cramps Mid-abdominal cramps
- 28. Diarrhea causes • Infection •Poorly absorbed sugars • Inflammatory bowel disease • Microscopic colitis • Functional bowel disorder
- 29. • Celiac disease •Pancreatic insufficiency • Hyperthyroidism • Ischemia • Endocrine tumor
- 30. GI Bleeding causes •Ulcer disease • Esophagitis Varices • Vascular lesions • Neoplasm • Diverticula
- 31. • Hemorrhoids • Fissures •Inflammatory bowel disease • Infectious colitis
- 32. Jaundice • Jaundice resultsfrom prehepatic, intrahepatic, or posthepatic disease.
- 33. Obstructive Jaundice causes •Bile duct stones • Cholangiocarcinoma • Cholangitis • Ampullary stenosis • Ampullary carcinoma • Pancreatitis • Pancreatic tumor
- 34. Evaluation of thePatient with GI Disease • History and examination. • Investigation
- 35. History • Symptoms ofshort duration commonly result from acute infection, toxin exposure, or abrupt inflammation or ischemia. • Long-standing symptoms point to underlying chronic inflammatory or neoplastic conditions or functional bowel disorders.
- 36. • Symptoms frommechanical obstruction, ischemia, inflammatory bowel disease, and functional bowel disorders are worsened by meals. • Peptic ulcer symptoms may be relieved by eating or antacids.
- 37. • Ulcer painoccurs at intermittent intervals lasting weeks to months. • Biliary colic has a sudden onset and lasts up to several hours. • Pain from acute pancreatitis is severe and persists for days to weeks.
- 38. • Meals elicitdiarrhea in some cases of inflammatory bowel disease and irritable bowel syndrome. • Defecation relieves discomfort in inflammatory bowel disease and irritable bowel syndrome. • Functional bowel disorders are exacerbated by stress.
- 39. • Diarrhea frommalabsorption usually improves with fasting. • Secretory diarrhea persists without oral intake.
- 40. • Obstructive symptomswith prior abdominal surgery raise concern for adhesions, whereas loose stools after gastrectomy suggest dumping syndrome. • Medications may produce pain, altered bowel habits, or GI bleeding. • Lower GI bleeding likely results from neoplasms, diverticula, or vascular lesions in an older person and from anorectal abnormalities or inflammatory bowel disease in a younger individual.
- 41. • A sexualhistory may raise concern for sexually transmitted diseases or immunodeficiency.
- 42. Physical Examination • Feversuggests inflammation or neoplasm. • Skin, eye, or joint findings may point to specific diagnoses. • Neck exam with swallowing assessment evaluates dysphagia.
- 43. • Pelvic examinationtests for a gynecologic source of abdominal pain. • Rectal exam may detect blood, indicating gut mucosal injury or neoplasm. • Abdominal distention may result from obstruction, tumor, or ascites or vascular abnormalities with liver disease.
- 44. • Palpation assessesfor hepatosplenomegaly as well as neoplastic or inflammatory masses. • Peritonitis have directed pain, often with involuntary guarding, rigidity, or rebound. • Percussion assesses liver size and can detect shifting dullness from ascites.
- 45. • Ecchymoses developwith severe pancreatitis. • Bruits or friction rubs from vascular disease or hepatic tumors. • Loss of bowel sounds signifies ileus. • High-pitched, hyperactive sounds characterize intestinal obstruction.
- 46. INVESTIGATIONS • Laboratory • Examinationof luminal contents • Radiographic • Functional tests • Histopathologic • Upper and lower endoscopy
- 47. Laboratory • Iron-deficiency anemiasuggests mucosal blood loss. • Vitamin B12 deficiency results from small- intestinal, gastric, or pancreatic disease. • Leukocytosis and increased sedimentation rates and C-reactive proteins are found in inflammatory conditions.
- 48. • Severe vomitingor diarrhea elicits electrolyte disturbances, acid-base abnormalities, and elevated blood urea nitrogen. • Pancreaticobiliary or liver disease is suggested by elevated pancreatic or liver chemistries. • Thyroid chemistries, cortisol, and calcium levels are obtained to exclude endocrinologic causes of GI symptoms.
- 49. • Serologic testscan screen for celiac disease, inflammatory bowel disease, rheumatologic diseases like lupus or scleroderma. • Intraabdominal malignancies produce other tumor markers including the carcinoembryonic antigen CA 19-9 and –Alpha fetoprotein.
- 50. • Ascitic fluidis analyzed for infection, malignancy, or findings of portal hypertension.
- 51. Luminal Contents • Stoolsamples are cultured for bacterial pathogens, examined for leukocytes and parasites, or tested for Giardia antigen. • Duodenal aspirates can be examined for parasites or cultured for bacterial overgrowth. • Fecal fat is quantified in possible malabsorption.
- 52. • Stool electrolytescan be measured in diarrheal conditions. • Gastric acid is quantified to rule out Zollinger- Ellison syndrome. • Pancreatic juice is analyzed for enzyme or bicarbonate content to exclude pancreatic exocrine insufficiency.
- 53. Endoscopy • May providethe diagnosis of the causes of bleeding, pain, nausea and vomiting, weight loss, altered bowel function, and fever. • Upper endoscopy evaluates the esophagus, stomach, and duodenum. • Colonoscopy assesses the colon and distal ileum. • Its ability to directly visualize as well as biopsy the abnormality.
- 54. • Upper endoscopyis performed in patients with suspected ulcer disease, esophagitis, neoplasm, malabsorption, and Barrett's metaplasia.
- 55. • Colonoscopy isthe procedure of choice for colon cancer screening and diagnosis of colitis secondary to infection, ischemia, radiation, and inflammatory bowel disease. • Sigmoidoscopy examines the colon up to the splenic flexure and is used to exclude distal colonic inflammation or obstruction in young patients.
- 56. • Capsule endoscopyalso can visualize small- intestinal Crohn's disease in individuals with negative barium radiography. • Endoscopic retrograde cholangiopancreaticography (ERCP) provides diagnoses of pancreatic and biliary disease.
- 57. Radiography/Nuclear Medicine • Oralor rectal contrast agents like barium provide mucosal definition of GIT & also assesses gut transit and pelvic floor dysfunction. • Barium swallow is the initial procedure for evaluation of dysphagia to exclude subtle rings or strictures and assess for achalasia.
- 58. • Contrast enemasare performed when colonoscopy is unsuccessful or contraindicated.
- 59. • Ultrasound andcomputed tomography (CT) evaluate regions not accessible by endoscopy or contrast studies, including the liver, pancreas, gallbladder, kidneys, and retroperitoneum. • Angiography excludes mesenteric ischema. • Positron emission tomography can facilitate distinguishing malignant from benign disease in several organ systems.
- 60. • Radiolabeled leukocytescans can search for intraabdominal abscesses not visualized on CT.
- 61. Histopathology • Gut mucosalbiopsies obtained for inflammatory, infectious, and neoplastic disease. • Deep rectal biopsies assist with diagnosis of Hirschsprung's disease or amyloid. • Liver biopsy is indicated in cases with abnormal liver chemistries, unexplained jaundice, following liver transplant to exclude rejection.
- 62. • Biopsies obtainedduring CT or ultrasound can evaluate for other intraabdominal conditions not accessible by endoscopy.
- 63. Functional Testing • Gastricacid and pancreatic function testing. • Esophageal manometry is useful for suspected achalasia. • Small-intestinal manometry tests for pseudoobstruction.
- 64. • Anorectal manometryis employed for unexplained incontinence or constipation. • Biliary manometry tests for sphincter of Oddi dysfunction with unexplained biliary pain. • Measurement of breath hydrogen while fasting and after oral mono- or oligosaccharide challenge to screen for carbohydrate intolerance.