Gastrointestinal Disease presentation

1. DIAGNOSTIC MEDICIE-2
CHOs in training-Year 3
Gastro-Intestinal System
Medicine
Dr. Brima Bobson Sesay
Medicine Department
Njala University-Bo Campus

2. PRESENT COMPLAINT
COMMON SYMPTOMS
 Anorexia and weight loss
 Dysphagia
 Heartburn
 Dyspepsia
 Nausea and vomiting
 Haematemesis
 Abdominal pain
 Wind
 Abdominal distension
 Altered bowel habit
 Rectal bleeding
 Jaundice

3. ANOREXIA AND WEIGHT LOSS
 Anorexia: loss of appetite
 Weight loss: energy expenditure exceeds
calorie intake
“Do you still enjoy your meals?”
CAUSES:
 DM type 1
 Hyperthyroidism
 Malabsorption
 Diuretic therapy
 Severe burns

4. DYSPHAGIA
 Difficulty swallowing
“Does food (or drink) stick when
you swallow?”
CAUSES:
 Oral
– Ulcers
– Mouth infections
 Neurological
– Stroke
– Bulbar palsy
 Neuromuscular
– Achalasia
– Myasthenia gravis
 Mechanical
– Oesophageal cancer

5. DYSPEPSIA
 Pain or discomfort centred in the upper abdomen
CAUSES:
 Gastro-oesophageal
reflux disease
 Peptic ulcer disease
 Functional dyspepsia

6. Symptoms of Dyspepsia
 Discomfort in the upper abdomen
 Bloating
 Early satiety
 Abdominal distension
 Nausea
 Indigestion

8. Pharmacological · treatment
 Cap. omeprazole 20 mg once a day 45 mins
before breakfast for 4 to 6 weeks or
 Tab. ranitidine 150 mg twice a day 45 mins.
before breakfast and dinner for 4 to 6·weeks.
 Antacids 2 to 3 teaspoon or 2 tabs
(chewable) when symptomatic despite above
medication.

9. Patient education
 Avoid excess tea, coffee, fried food item
 Abstain from alcohol and smoking. ·
 Avoid unnecessary NSAIDs: prefer
paracetamol especially in those with ulcer
like symptoms or with documented
duodenal/gastric ulcer. ·
 Follow meals at regular intervals 4 hourly
(including snacks)
 ·Daily exercise to maintain optimum weight

10. PEPTIC ULCER DISEASE
 There is ulceration of the gastric or duodenal mucosa due to
acid and pepsin.
Salient features
 Heart burn related with foods.
 History of NSAIDs or steroid ingestion.
 In advance cases upper abdominal pain, weight loss, anorexia,
cachexia.
 ·95% of duodenal ulcer and 60% gastric ulcers are related to H
Pylori and remaining related to NSAIDs intake.
 ·In case of perforation: severe abdominal pain, guarding,
rigidity, shock.

11. Pharmacological treatment
 Anti H.pylori treatment is recommended for patients
on long term NSAIDs, bleeding peptic ulcer.
 Preferred two-week triple therapy followed by Proton
Pump Inhibitors (PPI) for 3 weeks.
 Non-Helicobacter pylori peptic ulcer · PPI e.g. Cap.
omeprazole 20 mg for 4 to 6 weeks, 45 minutes
before breakfast. or
 Tab. ranitidine 150 mg BD or
 Tab. Famotidine 40 mg OD are equally efficacious
but takes longer time for symptom relief

12. Triple treatment for H. pylori

13. Patient education
 Stop smoking and curtail alcohol intake.
 Avoid NSAIDs, prefer paracetamol.
 Avoid foods which aggravate symptoms; no
role of bland diet or excess milk. ·Meals at
regular

14. NAUSEA AND VOMITING
 Nausea: sensation of feeling sick
 Vomiting: expulsion of gastric contents via mouth.
CAUSES:
 Dyspepsia
 Peptic ulcers
 Gastric outlet/ pylorus
obstruction
 Gastroenteritis
 Cholecystitis
 Raised intracranial
pressure

15. VOMITING
 Vomiting is the forceful expulsion of the
gastric contents due to contraction of
abdominal musculature and simultaneous
relaxation of gastric fundus and lower
esophageal sphincter.

16. Pharmacological treatment
 Hospitalize the patient to give intravenous fluids in case of
dehydration.
 Start oral fluids as soon as the patient can tolerate.
 Acute vomiting : Rule out gastric outlet obstruction then Inj.
ondansetron 8 mg IV repeat 8 hourly if needed Or Inj.
metoclopramide 10 mg IM, repeat after 6 hours if needed Or
Tab. domperidone 10 mg TDS Or Tab. metoclopramide 10 mg
TDS
 ·In pregnancy avoid all drugs, if possible. Tab. promethazine 25
mg oral/injection is safe in the first trimester
 If there is history of motion sickness then give Tab. cyclizine 50
mg TDS.

17. Patient education
 Avoid stale food, vegetables, fruits kept in open,
drink boiled water only.
 Avoid NSAIDs, especially if ulcer symptoms are
present.
 Prevent dehydration: Encourage patients to take sips
of liquids at short intervals to prevent dehydration.
 Endoscopy is necessary, if symptom persists.
 Prevent motion sickness by avoiding heavy meal
before travel.

18. HAEMATEMESIS (UPPER GASTROINTESTINAL
BLEEDING).
 Vomiting blood
 Above g-o sphincter (oesophageal varices)
 Below g-o sphincter (Mallory-Weiss tear)
CAUSES:
 Gastric ulcer
 Oesophagitis, gastritis
 Oesophagic, gastric
cancer
 NSAIDS

19. Investigations
 Hemoglobin levels
 Blood grouping
 PT,
 APTT
 Upper Gastrointestinal scopy,
 ultrasonography

20. Treatment:
Pharmacological treatment:
 Get wide bore access with I.V.Cannula (16G
preferable) for rapid fluid resuscitation,
 Ryle's tube insertion and catheterization
 Inj. pantoprazole 40 mg IV12 hourly,
 Inj. tranexamic acid 500 mg TDS
 Inj. octreotide 100 mcg IV 6 hourly,

21. Pharmacological Treatment Cont.
 Banding oesophageal varices,
 Gastric balloon
 Blackmore tube- in oesophageal varices,
 Injection sclerotherapy- in oesophageal varices,
 Argon diathermy or laser in peptic ulcers.
Surgical treatments:
 Exploratory laprotomy and search for the cause and
treat the cause or TIPPS (Trans jugular intrahepatic
portosystemic shunts) - in uncontrolled portal
hypertension .

22. ABDOMINAL PAIN
Access its characteristics!
(site, timing, severity, what makes it
worse and what makes it better)
 Visceral abdominal pain: distension of hollow organs,
smooth muscle contraction (deep poorly localized)
 Somatic pain: irritation of parietal peritoneum
Hindgut – pain localizes to suprapubic area
Midgut – pain localizes to periumbilical area
Foregut – pain localizes to epigastric area

23. ACUTE PANCREATITIS
 Acute pancreatitis is the most common
pathology of pancreas.
 It ranges from self limiting mild pancreatitis to
life threatening necrotizing pancreatitis
(accounts for 10- 20% of total cases).

24. Causes of acute pancreatitis
 Alcoholism
 Gall stone disease,
 Hypercholesterolemia
 Hypercalcemia,
 Hypomagnesemia,
 Viral infections,
 familial pancreatitis,
 idiopathic and other

25. Salient features
 Epigastric pain
 History of alcoholism,
 Gall stone disease
 Cholesterol and metabolic abnormalities,
 History of similar complaints in family.
Per abdomen examination:
 Tenderness, Guarding, Rigidity.
 Look for fever, tachycardia, tachypnea and symptoms
of shock.

26. Investigations
 TC / DC which shows increase with neutrophillia, S.
Amylase- increased more than 3 fold normal value,
S. Lipase (more specific)- increased more than 3 fold
of normal value, S. Calcium below normal values.
 USG- Abdomen- shows edema of pancreas,
necrosis,
 CECT- Abdomen (in unresolving and severe cases),
delineates pancreatic anatomy more clearly,
 Chest X ray, to rule out systemic complications like
acute respiratory distress syndrome (ARDS)

27. Pharmacological treatment for Acute non
necrotizing pancreatitis
 Non- Nil by mouth
 Nasogastric tube insertion,
 Avoid alcohol Pharmacological treatment ·
 Fluid resuscitation,
 Correction of electrolyte imbalance
 Inj. diclofenac sodium 75 mg IM 8 hourly and gradually
proceeding towards opioid analgesic like Inj. tramadol 50 mg
once day.
 Inj. pantoprazole 40 mg IV 12 hourly and Inj. octreotide 100
mcg IV/SC 6 to 12 hourly till symptoms resolve.

28. Surgical treatment
 ·Usually no surgical intervention is required
for acute non necrotizing pancreatitis.
 Cholecystectomy for gall stone pancreatitis
after acute pancreatitis is resolved.

29.  Acute necrotising pancreatitis Non
Pharmacological treatment ·ICU monitoring,
oxygen by mask, nil by mouth, nasogastric
tube insertion, per urethral catheterizatio

30. Non Pharmacological treatment For Acute
necrotizing pancreatitis
 ICU monitoring
 oxygen by mask,
 Nil by mouth,
 Nasogastric tube insertion,
 Per urethral catheterizatio

31. Pharmacological treatment For Acute
necrotizing pancreatitis
 Fluid resuscitation,
 Correction of electrolyte imbalance
 Inj. diclofenac sodium 75 mg IM 8 hourly
 Inj. pantoprazole 40 mg IV12 hourly
 Inj. octreotide 100 mcg IV/SC every 6 hourly
to 8 hourly
 Inj. meropenem 1 gm IV8 hourly

32. CHRONIC PANCREATITIS
 It is characterized by pancreatic atrophy,
fibrosis, calcification and at times ductal
dilatation.
 It is most commonly caused by repeated
alcoholic pancreatitis.

33. Salient features
 ·Dull epigastric pain
 Weight loss
 Malnutrition,
 Type I diabetes
 History of alcoholism,
 History of previous attacks of acute
pancreatitis.
 Signs of cachexia

34. Investigation
 X-ray abdomen may show calcification in pancreatic
region.
 USG abdomen shows atrophic pancreas with or
without foci of calcification and ductal dilatation.
 Magnetic Resonance Cholangiopancreatography
(MRCP) gives excellent anatomy of ductal system.
 Endoscopic Retrograde Cholangiopancreatography
(ERCP) is reserved for chronic pancreatitis due to
peri ampullary obstruction

35. Treatment for chronic Pancreatitis
Non - pharmacological treatment for chronic
Pancreatitis
 Avoidance of alcohol, low fat, low protein diet
Pharmacological treatment for Chronic Pancreatitis
 Enteric coated pancreatic enzymes for replacement of
pancreatic function.
 ·Inj. diclofenac sodium 75 mg IM 8 hourly and gradually
proceeding towards opioid analgesic like Inj. tramadol 50 mg
·Inj. pantoprazole 40 mg IV12 hourly
Surgical treatment ·Indicated in severe pain non responding to
pharmacological therapy

36. WIND
 Repeated belching, excessive flatus, abdominal
distension
 Borborygmi: bowel sounds, movement of fluid and
gas along the intestine
Ask the patient to describe what is
being experienced.

37. CONSTIPATION
Salient features
 Constipation is defined as decrease in frequency and liquidity of
stool compared ·to the normal pattern.
 Important complaints suggesting constipation include straining at
defaecation, lumpy/hard stools, sensation of incomplete evacuation,
or less than 3 bowel ·actions per week.
 The important contributory factors being insufficient dietary fiber,
physical inactivity, suppression of defaecatory urges occurring at
inconvenient moments, ·prolonged travel etc.
 The important secondary causes may include neurological,
hormonal, colonic, malignancy, depression. Secondary causes
should be looked for in case of recent onset or constipation of
severe symptoms.

38. Treatment for Constipation
Non- pharmacological treatment:-
 Reassurance - since many patients with normal stools and
with pregnancy feel that they are constipated.
 High fiber diet and increased intake of fluid with decrease
in consumption of caffeinated drinks.
 Retraining of bowel evacuation (avoiding suppression of
urge to defecate, making a regular habit).
 Bulk forming agents to help relieve mild constipation.
 Regular physical exercise such as walk for 1/2 to 1 hour
daily and abdominal exercises.

39. Treatment of chronic Constipation
Pharmacological treatment (usually required for moderate to
severe constipation).
 Lactulose solution 15-20 ml orally at night or Susp. magnesium
sulphate 15-20 ml at night or Tab. sodium picosulphate 10 mg
at night or Isotonic polyethylene glycol (PEG) electrolyte
solution 125-250 ml.
 Any of these may be given 2-4 times a week. Some patients
may require treatment for several weeks or months if there is
no improvement.

40. Treatment cont.
 Tab. mosapride 5 mg 2 or 3 times a day. If
required, the duration of treatment can be
extended.
 Phosphate enemas to be used on as and
when required basis in patients having acute
problem with severe constipation or sub-
acute intestinal obstruction

41. ABDOMINAL DISTENSION
 Factors (the 5 Fs)
– FAT
– FLATUS
– FAECES
– FLUID
– FOETUS
Consider
– Excessive alcohol consumption
– Obstruction
– Obstruction, constipation
– Ascites
– Date of last menstrual period

42. ALTERED BOWEL HABIT
 3x each day to 1x every 3 days is considered
normal
 Constipation: infrequent passage of hard
stools
– Impaired mobility
– Physical obstruction
 Diarrhoea: frequent passage of loose stools
– Impaired water absorption
Ask for change in stool consistency,
increased frequency of defecation,
urgency, etc

43. RECTAL BLEEDING
 Fresh rectal bleeding
– Haemorrhoids
– Anal fissure
– Colorectal cancer
– IBD
 Melaena: blood loss in upper
GIT tract

44. JAUNDICE
 Yellow discoloration of the skin, sclerae and mucous
membrames (> 50 μmol/L)
 Hyperbilirubinaemia
– Prehepatic (haemolysis, Gillbert’s syndrome) +Ubg
– Hepatocellular (viral hepatitis, drugs, cirrhosis)
– Obstructive (drugs, gallstones, cancer) +UnBil

45. PAST HISTORY
 Similar problem might suggest diagnosis
 Previous abdominal surgery
 OTCs
 Aspirin and NSAIDs
 Opioids
 Antibiotics

46. FAMILY HISTORY
 Colorectal cancer in a < 50 years
old, first degree patient
 IBD
 Crohn’s disease
 Ulcerative colitis
 +ve family history in most of GIT
diseases is not helpful

47. SOCIAL HISTORY
 Dietary history
 Alcohol consumption
 Smoking
 Stress
 Specific risk factors

48. Thanks!!!!!!