SlideShare a Scribd company logo
1 of 5
Download to read offline
Survival Guide:
         Gastroenterology

Contents
  • What’s it all about?
  • Conditions you may be asked about in the first week
  • Abdominal pain
  • GI bleeding
  • Diarrhea
  • Gastroesophageal reflux disease
  • Do’s and Don’ts
  • History and physical examination


                                          Copyright © 2004 Elsevier
What’s it all about?
Gastroenterology is a subspecialty of internal medicine. It deals with conditions and diseases of
the organs of the digestive tract and associated solid organs such as the pancreas, liver, and
gallbladder. The most frequent complaints seen in the clinic and the hospital include abdominal
pain, nausea, vomiting, diarrhea and GI bleeding.

Management of gastrointestinal problems can be both medical and surgical. A key aspect of GI is
learning to differentiate benign processes from those that are more serious and possibly needing
a procedure or surgical intervention.


Conditions you may be asked about in the first week
The conditions you will usually be asked about in your first week are the more common
complaints and diagnoses. The most important things you will be asked involve differential
diagnoses, and how to work up the problem. The most common problems in gastroenterology
include:
     • abdominal pain,
     • differentiating and working up a GI bleed,
     • diarrhea, and
     • gastroesophageal reflux disease.

You may also come across other common conditions as you progress, such as: peptic ulcer
disease, appendicitis, diverticulitis, colon cancer, hepatitis, cirrhosis, cholecystitis, pancreatitis,
irritable bowel syndrome and inflammatory bowel syndrome.


Abdominal pain
PQRST
  • Presentation: ‘How?’ and ‘Where?’
  • Quality: ‘Is the pain sharp, dull, burning, colicky?’
  • Radiation: ‘Does the pain radiate anywhere (e.g. groin, back, shoulder)?’
  • Severity: ‘How bad is the pain on a scale of 1 to 10?’, ‘What makes it better or worse?’
  • Timing: ‘When does it occur?’, ‘How long?’, ‘Associations?’

The chronological sequence of events in the patient's history is often more important than
emphasis on the location of pain.

Careful attention should be paid to the extra-abdominal regions that may be responsible for
abdominal pain. An accurate menstrual history in a female patient is essential.

Abdominal examinations are mandatory in every patient with abdominal pain.
Pelvic and rectal examinations are recommended in patients with lower abdominal pain
especially if the pain is acute.

Differential diagnosis

Some causes of abdominal pain are obvious, some less so. It’s best to associate pain with
quadrants. The following guidelines are meant to be general, because all disorders have been
known to present atypically.
   • Right upper quadrant: Biliary colic, cholangitis, cholecystitis, pyelonephritis, renal colic,
       renal infarct, pneumonia, hepatic abscess, hepatitis, retrocecal appendicitis, pelvic
       inflammatory disease (PID).
•   Left upper quadrant: Splenic infarct, pancreatitis, pyelonephritis, renal colic, renal
        infarct, pneumonia, PID.
    •   Epigastric: Gastritis, gastric ulcer, duodenal ulcer, pancreatitis, carcinoma, pancreatic
        cancer, reflux esophagitis (sub-sternal pain).
    •   Right lower quadrant: Appendicitis, ovarian cyst/torsion, ectopic pregnancy, salpingitis,
        urinary tract infection (UTI), renal colic, Crohn’s disease, colitis, cancer, PID.
    •   Left lower quadrant: Diverticulitis, colitis, sigmoid volvulus, ovarian cyst/torsion, ectopic
        pregnancy, renal colic, UTI, PID.
    •   Suprapubic: Appendicitis, diverticulitis, salpingitis, uterine fibroid, ovarian cyst, cystitis,
        PID.



GI bleed
The first step in working up a GI bleed is to assess your patient’s age:
   • patients under the age of 60 have a mortality of <1%;
   • patients over 80 have a mortality of >20%

Check also for shock, renal disease, liver disease and cardiovascular disease (including
hypertension) – these all increase the chances that your patient may die.

Check your patient’s vital signs and make sure they are stable. Initial resuscitation requires
restoration of intravascular volume, correction of coagulopathy and airway protection.

Once it has been determined that the patient is stable, initial work-up includes nasogastric (NG)
aspiration, rectal exam and Hemoccult, endoscopy and colonoscopy, barium studies, radionuclide
imaging (this can detect a bleeding rate as low as 0.1 mL/min, but is only positive about 45% of
the time) and angiography (a bleed must exceed 0.5 mL/min to be detected). Weigh up the
significant pros and cons of each of the above.

Upper GI bleeding
   • Hematemesis, melena > hematochezia, tachycardia, hypotension.
   • Evaluation: endoscopy if stable (this is urgent in patients with an active bleed and/or liver
       disease), NG tube and NG lavage.
   • Common causes: peptic ulcer disease, gastritis, esophageal varices, vascular
       abnormalities, Mallory-Weiss tear, neoplasm, esophagitis, stress ulcer.
   • Initial management: protect airway, stabilize with IV fluids, blood products.
   • Further management: endoscopy followed by therapy directed at underlying cause.

Lower GI bleeding
   • Hematochezia > melena, but can be either.
   • Rule out upper GI bleed with NG tube and NG lavage, colonoscopy if stable.
   • Common causes: diverticulosis, arteriovenous malformations, colon cancer, inflammatory
      bowel disease, anorectal disease, mesenteric ischemia.
   • Initial management: stabilize patient with IV fluids, blood products if necessary.
   • Further management: rule out upper GI bleed; colonoscopy and management directed at
      underlying cause (eg. surgical resection of cancer, diverticula).
Diarrhea
Hx should include duration, frequency, estimated volume and consistency of each bowel
movement, relation to meals, associated fever, pain, nausea, vomiting, blood in stool, history of
travel, medication use.

Major types of diarrhea are secretory, osmotic, exudative.
   • Secretory: Enterotoxins (Cholera, E. coli, S. aureus), gastric hypersecretion, laxative
        abuse.
   • Osmotic: Malabsorption.
   • Exudative: Shigella, Salmonella, C. difficile.

Infection is the most common cause of diarrhea, and is usually caused by food poisoning.

Initial workup includes CBC with differential, chemistry panel with BUN and creatinine. WBCs in
stool indicate CHESS organisms:

    •   Campylobacter.
    •   Hemorrhagic E. coli.
    •   Entamoeba histolytica.
    •   Salmonella.
    •   Shigella.

Treatment consists of correction of fluid and electrolyte abnormalities and reduction of symptoms.
Avoid antibiotics in enteric salmonella infection because a prolonged carrier state may be
induced. Antimotility agents should be used cautiously with inflammatory diarrhea.


Gastroesophageal reflux disease
Gastroesophageal reflux disease is symptomatic reflux of gastric contents into the esophagus. It
is one of the most common conditions you will see . Symptoms include heartburn, chest pain,
regurgitation, belching, dysphagia, and halitosis. Additional pulmonary symptoms including
chronic cough, hoarseness, wheezing and asthma. If you see a patient who complains of chronic
tickle in the back of the throat with associated cough, consider gastroesophageal reflux disease
after ruling out other possibilities. Ask your patient whether pain wakes them up at night—this
generally is NOT reflux and more likely associated with ulcer disease.

Risk factors include smoking, drinking alcohol, eating chocolate or mints, hiatal hernia, obesity,
increased intra-abdominal pressure, and increased plasma progesterone levels.

Diagnosis is usually based on history.
    • Barium swallow: least sensitive test.
    • 24hr pH monitoring: gold-standard for measuring GERD (pH <4).
    • Manometry: may detect transient lower esophageal sphincter (LES) relaxation, hiatal
       hernia.
    • Esophagogastroduodenoscopy (EGD) with biopsies, if patient has long-standing
       symptoms – to rule out Barrett’s esophagus and adenocarcinoma.
    • Acid-perfusion test (Bernstein test) can be done but is becoming less common.
Treatment includes lifestyle changes, drug management and surgery.
    • Lifestyle: weight loss, elevate head of bed, avoid certain foods.
    • Drugs: antacids, H2-receptor antagonists or proton pump inhibitors (PPIs).
    • Surgery: nissen fundoplication if refractory or severe disease.

Complications include ulceration, strictures, upper GI bleeding, aspiration and risk of pneumonia,
Barrett’s esophagus (which may lead to adenocarcinoma of the esophagus).


Do’s and Don’ts
    •   ALWAYS remember to ask women about their menstrual cycle and sexual activity since
        many gynecological and obstetrical conditions can mimic GI complaints.
    •   Do perform a rectal exam in association with Hemoccult. No-one likes having a rectal
        exam, but it is almost always pertinent, especially when ruling out GI bleeding.


History and physical examination
Ask about bowel habits and any changes in them, flatus, nausea, vomiting, dark or tarry stools,
and association of symptoms with eating or types of food. Ask the patient to point to the location
of the pain before initiating the exam.
     • Inspect the abdomen, particularly noting the contour, any scars and locations, and
        noticeable masses or bulges.
     • Listen for bowel sounds as well as abdominal aortic and renal bruits.
     • Percuss the abdomen; tympanic abdomen suggests obstruction.
     • Always start palpation away from areas of pain.
     • Do light palpation followed by deeper palpation; note any masses or muscle rigidity
        (“guarding”).

Percussion is also a good way to test for “rebound” tenderness or acute abdomen. Some
physicians may try to bump the bed or exam table to assess for peritoneal inflammation, as well
as asking their patient to cough or just percuss the abdomen; these will usually elicit “rebound” as
well. BUT always consider your patient’s comfort – testing for rebound causes additional pain and
you should make sure that it is absolutely necessary.


Author
By Matthew Reinersman, Southern Illinois University School of Medicine.

More Related Content

What's hot

Intestinal obstruction2
Intestinal obstruction2Intestinal obstruction2
Intestinal obstruction2
Larissa Sams
 
small intestine diseases 2
small intestine diseases 2small intestine diseases 2
small intestine diseases 2
Deep Deep
 

What's hot (20)

Intestinal obstruction by Dr.Usman Haqqani
Intestinal obstruction by Dr.Usman HaqqaniIntestinal obstruction by Dr.Usman Haqqani
Intestinal obstruction by Dr.Usman Haqqani
 
Gastrointestinal System
Gastrointestinal SystemGastrointestinal System
Gastrointestinal System
 
Intestinal obstruction2
Intestinal obstruction2Intestinal obstruction2
Intestinal obstruction2
 
Intestinal obstruction
Intestinal obstructionIntestinal obstruction
Intestinal obstruction
 
Paralytic ileus (adynamic intestinal obstruction)
Paralytic ileus (adynamic intestinal obstruction)Paralytic ileus (adynamic intestinal obstruction)
Paralytic ileus (adynamic intestinal obstruction)
 
Hernia
HerniaHernia
Hernia
 
Hiatal hernia
Hiatal hernia Hiatal hernia
Hiatal hernia
 
Intestinal Obstruction
Intestinal ObstructionIntestinal Obstruction
Intestinal Obstruction
 
intestinal obstruction
intestinal obstructionintestinal obstruction
intestinal obstruction
 
Intestinal obstruction
Intestinal obstructionIntestinal obstruction
Intestinal obstruction
 
La boob
La boobLa boob
La boob
 
Intestinal Obstruction
Intestinal ObstructionIntestinal Obstruction
Intestinal Obstruction
 
Intussusception
IntussusceptionIntussusception
Intussusception
 
Bowel obstruction
Bowel obstructionBowel obstruction
Bowel obstruction
 
small intestine diseases 2
small intestine diseases 2small intestine diseases 2
small intestine diseases 2
 
Hernia
HerniaHernia
Hernia
 
Small bowel obstruction
Small bowel obstructionSmall bowel obstruction
Small bowel obstruction
 
Imaging modalities of intestinal obstruction Mithilesh Kumar Medical College ...
Imaging modalities of intestinal obstruction Mithilesh Kumar Medical College ...Imaging modalities of intestinal obstruction Mithilesh Kumar Medical College ...
Imaging modalities of intestinal obstruction Mithilesh Kumar Medical College ...
 
Volvulus
VolvulusVolvulus
Volvulus
 
Intestinal obstruction
Intestinal obstructionIntestinal obstruction
Intestinal obstruction
 

Viewers also liked

Rubzzzz's Nervous system on Hx taking
Rubzzzz's Nervous system on Hx takingRubzzzz's Nervous system on Hx taking
Rubzzzz's Nervous system on Hx taking
Dr. Rubz
 
Learning outcome in Pediatric
Learning outcome in PediatricLearning outcome in Pediatric
Learning outcome in Pediatric
Dr. Rubz
 
Cardiac failure ( long case approach ) summary
Cardiac failure ( long case approach ) summaryCardiac failure ( long case approach ) summary
Cardiac failure ( long case approach ) summary
Dr. Rubz
 
Cpg child immunisation
Cpg child immunisationCpg child immunisation
Cpg child immunisation
Dr. Rubz
 
Short case approach to speech analysis summary
Short case approach to speech analysis summaryShort case approach to speech analysis summary
Short case approach to speech analysis summary
Dr. Rubz
 
Guides on Heart Disease
Guides on Heart DiseaseGuides on Heart Disease
Guides on Heart Disease
Dr. Rubz
 
Febrile summary
Febrile summaryFebrile summary
Febrile summary
Dr. Rubz
 
Rubzzzz's Neurology Case Hx 4th year
Rubzzzz's Neurology Case Hx 4th yearRubzzzz's Neurology Case Hx 4th year
Rubzzzz's Neurology Case Hx 4th year
Dr. Rubz
 
Guides on GI system
Guides on GI systemGuides on GI system
Guides on GI system
Dr. Rubz
 
Short case approach to cushing summary
Short case approach to cushing summaryShort case approach to cushing summary
Short case approach to cushing summary
Dr. Rubz
 
Guidelines of Epilepsy by NICE
Guidelines of Epilepsy by NICEGuidelines of Epilepsy by NICE
Guidelines of Epilepsy by NICE
Dr. Rubz
 
O&g examination
O&g examinationO&g examination
O&g examination
Dr. Rubz
 
Short case approach to acromegaly summary
Short case approach to acromegaly summaryShort case approach to acromegaly summary
Short case approach to acromegaly summary
Dr. Rubz
 
Short case approach to parkinson's dz summary
Short case approach to parkinson's dz summaryShort case approach to parkinson's dz summary
Short case approach to parkinson's dz summary
Dr. Rubz
 
Gina asthma management
Gina asthma managementGina asthma management
Gina asthma management
Dr. Rubz
 
Chronic renal failure concise long case approach & crf with fluid overload m...
Chronic renal failure concise long case approach  & crf with fluid overload m...Chronic renal failure concise long case approach  & crf with fluid overload m...
Chronic renal failure concise long case approach & crf with fluid overload m...
Dr. Rubz
 
Neurological examination summary
Neurological examination summaryNeurological examination summary
Neurological examination summary
Dr. Rubz
 

Viewers also liked (20)

Rubzzzz's Nervous system on Hx taking
Rubzzzz's Nervous system on Hx takingRubzzzz's Nervous system on Hx taking
Rubzzzz's Nervous system on Hx taking
 
Learning outcome in Pediatric
Learning outcome in PediatricLearning outcome in Pediatric
Learning outcome in Pediatric
 
Cardiac failure ( long case approach ) summary
Cardiac failure ( long case approach ) summaryCardiac failure ( long case approach ) summary
Cardiac failure ( long case approach ) summary
 
Bohomolets Oncology Practical Methodical #1
Bohomolets Oncology Practical Methodical #1Bohomolets Oncology Practical Methodical #1
Bohomolets Oncology Practical Methodical #1
 
Cpg child immunisation
Cpg child immunisationCpg child immunisation
Cpg child immunisation
 
Short case approach to speech analysis summary
Short case approach to speech analysis summaryShort case approach to speech analysis summary
Short case approach to speech analysis summary
 
Guides on Heart Disease
Guides on Heart DiseaseGuides on Heart Disease
Guides on Heart Disease
 
Febrile summary
Febrile summaryFebrile summary
Febrile summary
 
Rubzzzz's Neurology Case Hx 4th year
Rubzzzz's Neurology Case Hx 4th yearRubzzzz's Neurology Case Hx 4th year
Rubzzzz's Neurology Case Hx 4th year
 
Guides on GI system
Guides on GI systemGuides on GI system
Guides on GI system
 
Bohomolets 3rd year Surgery Peritonitis
Bohomolets 3rd year Surgery PeritonitisBohomolets 3rd year Surgery Peritonitis
Bohomolets 3rd year Surgery Peritonitis
 
Short case approach to cushing summary
Short case approach to cushing summaryShort case approach to cushing summary
Short case approach to cushing summary
 
Guidelines of Epilepsy by NICE
Guidelines of Epilepsy by NICEGuidelines of Epilepsy by NICE
Guidelines of Epilepsy by NICE
 
O&g examination
O&g examinationO&g examination
O&g examination
 
Short case approach to acromegaly summary
Short case approach to acromegaly summaryShort case approach to acromegaly summary
Short case approach to acromegaly summary
 
Short case approach to parkinson's dz summary
Short case approach to parkinson's dz summaryShort case approach to parkinson's dz summary
Short case approach to parkinson's dz summary
 
Gina asthma management
Gina asthma managementGina asthma management
Gina asthma management
 
HIV/AIDS data Hub Asia Pacific -Malaysia 2014
HIV/AIDS data Hub Asia Pacific -Malaysia  2014HIV/AIDS data Hub Asia Pacific -Malaysia  2014
HIV/AIDS data Hub Asia Pacific -Malaysia 2014
 
Chronic renal failure concise long case approach & crf with fluid overload m...
Chronic renal failure concise long case approach  & crf with fluid overload m...Chronic renal failure concise long case approach  & crf with fluid overload m...
Chronic renal failure concise long case approach & crf with fluid overload m...
 
Neurological examination summary
Neurological examination summaryNeurological examination summary
Neurological examination summary
 

Similar to Guides on Gastroenterology

Part IV Gasitrointesitinal disorders pharmacotherapy.pptx
Part IV  Gasitrointesitinal disorders pharmacotherapy.pptxPart IV  Gasitrointesitinal disorders pharmacotherapy.pptx
Part IV Gasitrointesitinal disorders pharmacotherapy.pptx
AbdiIsaq1
 
Appendicitis, diverticulitis, peptic ulcer disease, chron's disease
Appendicitis, diverticulitis, peptic ulcer disease, chron's diseaseAppendicitis, diverticulitis, peptic ulcer disease, chron's disease
Appendicitis, diverticulitis, peptic ulcer disease, chron's disease
haron taufiq
 

Similar to Guides on Gastroenterology (20)

Gastrointestinal.bcgvcxg xfhcdgvcfhccghn
Gastrointestinal.bcgvcxg xfhcdgvcfhccghnGastrointestinal.bcgvcxg xfhcdgvcfhccghn
Gastrointestinal.bcgvcxg xfhcdgvcfhccghn
 
GI System Lecture 3
GI System Lecture 3GI System Lecture 3
GI System Lecture 3
 
Presentation on small intestine disorder
Presentation on small intestine disorder Presentation on small intestine disorder
Presentation on small intestine disorder
 
Biliary System Lecture
Biliary System LectureBiliary System Lecture
Biliary System Lecture
 
Diverticular disease of the colon hegazy
Diverticular disease of the colon hegazyDiverticular disease of the colon hegazy
Diverticular disease of the colon hegazy
 
Pathology and Management of Malignant ascites
Pathology and Management of Malignant ascitesPathology and Management of Malignant ascites
Pathology and Management of Malignant ascites
 
Gatrointestinal assessment
Gatrointestinal assessmentGatrointestinal assessment
Gatrointestinal assessment
 
Peptic ulcer
Peptic ulcerPeptic ulcer
Peptic ulcer
 
Acute Abdomen.pptx
Acute Abdomen.pptxAcute Abdomen.pptx
Acute Abdomen.pptx
 
peptic ulcer disease.pptx
peptic ulcer disease.pptxpeptic ulcer disease.pptx
peptic ulcer disease.pptx
 
peptic ulcer disease.pptx
peptic ulcer disease.pptxpeptic ulcer disease.pptx
peptic ulcer disease.pptx
 
Part IV Gasitrointesitinal disorders pharmacotherapy.pptx
Part IV  Gasitrointesitinal disorders pharmacotherapy.pptxPart IV  Gasitrointesitinal disorders pharmacotherapy.pptx
Part IV Gasitrointesitinal disorders pharmacotherapy.pptx
 
Acute abdomen
Acute abdomenAcute abdomen
Acute abdomen
 
Diarrhoea
DiarrhoeaDiarrhoea
Diarrhoea
 
Epigastric pain differential diagnosis
Epigastric pain differential diagnosisEpigastric pain differential diagnosis
Epigastric pain differential diagnosis
 
Acute Abdomen .pptx
Acute Abdomen .pptxAcute Abdomen .pptx
Acute Abdomen .pptx
 
ACUTE ABDOMEN pptx
ACUTE ABDOMEN pptxACUTE ABDOMEN pptx
ACUTE ABDOMEN pptx
 
Appendicitis, diverticulitis, peptic ulcer disease, chron's disease
Appendicitis, diverticulitis, peptic ulcer disease, chron's diseaseAppendicitis, diverticulitis, peptic ulcer disease, chron's disease
Appendicitis, diverticulitis, peptic ulcer disease, chron's disease
 
Gastroenterology
GastroenterologyGastroenterology
Gastroenterology
 
Acute cholecystitis.pptx
Acute cholecystitis.pptxAcute cholecystitis.pptx
Acute cholecystitis.pptx
 

More from Dr. Rubz

Ulc auction final
Ulc auction finalUlc auction final
Ulc auction final
Dr. Rubz
 
Hernia by Dr. Rubzzz
Hernia by Dr. RubzzzHernia by Dr. Rubzzz
Hernia by Dr. Rubzzz
Dr. Rubz
 
Benign breast disease by Dr. Kong
Benign breast disease by Dr. KongBenign breast disease by Dr. Kong
Benign breast disease by Dr. Kong
Dr. Rubz
 
Breast CA by Dr. Celine Tey
Breast CA by Dr. Celine TeyBreast CA by Dr. Celine Tey
Breast CA by Dr. Celine Tey
Dr. Rubz
 
Other scrotal swelling by Dr. Teo
Other scrotal swelling by Dr. TeoOther scrotal swelling by Dr. Teo
Other scrotal swelling by Dr. Teo
Dr. Rubz
 
Ventral hernia by Dr Teo
Ventral hernia by Dr TeoVentral hernia by Dr Teo
Ventral hernia by Dr Teo
Dr. Rubz
 
Testicular torsion by Dr Teo
Testicular torsion by Dr TeoTesticular torsion by Dr Teo
Testicular torsion by Dr Teo
Dr. Rubz
 
Uk malaria treatment guideline
Uk malaria treatment guidelineUk malaria treatment guideline
Uk malaria treatment guideline
Dr. Rubz
 
Tuberculosis summary
Tuberculosis summaryTuberculosis summary
Tuberculosis summary
Dr. Rubz
 
Shock summary
Shock summaryShock summary
Shock summary
Dr. Rubz
 
Stroke ( concise long case approach ) summary
Stroke ( concise long case approach ) summaryStroke ( concise long case approach ) summary
Stroke ( concise long case approach ) summary
Dr. Rubz
 

More from Dr. Rubz (20)

HIV discrimination among health providers in Malaysia by Dr Rubz
HIV discrimination among health providers in Malaysia by Dr RubzHIV discrimination among health providers in Malaysia by Dr Rubz
HIV discrimination among health providers in Malaysia by Dr Rubz
 
Regional Overview in HIV by Steve Kraus
Regional Overview in HIV by Steve KrausRegional Overview in HIV by Steve Kraus
Regional Overview in HIV by Steve Kraus
 
Game Changer by Dr Shaari Ngadiman
Game Changer by Dr Shaari NgadimanGame Changer by Dr Shaari Ngadiman
Game Changer by Dr Shaari Ngadiman
 
Pre and post HIV counseling (VCT)
Pre and post HIV counseling (VCT)Pre and post HIV counseling (VCT)
Pre and post HIV counseling (VCT)
 
Ulc auction final
Ulc auction finalUlc auction final
Ulc auction final
 
Testicular cancer for public awareness by Dr Rubz
Testicular cancer for public awareness by Dr RubzTesticular cancer for public awareness by Dr Rubz
Testicular cancer for public awareness by Dr Rubz
 
Prostate cancer for public awareness by DR RUBZ
Prostate cancer for public awareness by DR RUBZProstate cancer for public awareness by DR RUBZ
Prostate cancer for public awareness by DR RUBZ
 
Breast Cancer for public awareness by Dr Rubz
Breast Cancer for public awareness by Dr  RubzBreast Cancer for public awareness by Dr  Rubz
Breast Cancer for public awareness by Dr Rubz
 
Sex work presentation 9.18.13a
Sex work presentation 9.18.13aSex work presentation 9.18.13a
Sex work presentation 9.18.13a
 
Rapid interpretation of ECG
Rapid interpretation of ECGRapid interpretation of ECG
Rapid interpretation of ECG
 
Hernia by Dr. Rubzzz
Hernia by Dr. RubzzzHernia by Dr. Rubzzz
Hernia by Dr. Rubzzz
 
Benign breast disease by Dr. Kong
Benign breast disease by Dr. KongBenign breast disease by Dr. Kong
Benign breast disease by Dr. Kong
 
Breast CA by Dr. Celine Tey
Breast CA by Dr. Celine TeyBreast CA by Dr. Celine Tey
Breast CA by Dr. Celine Tey
 
Other scrotal swelling by Dr. Teo
Other scrotal swelling by Dr. TeoOther scrotal swelling by Dr. Teo
Other scrotal swelling by Dr. Teo
 
Ventral hernia by Dr Teo
Ventral hernia by Dr TeoVentral hernia by Dr Teo
Ventral hernia by Dr Teo
 
Testicular torsion by Dr Teo
Testicular torsion by Dr TeoTesticular torsion by Dr Teo
Testicular torsion by Dr Teo
 
Uk malaria treatment guideline
Uk malaria treatment guidelineUk malaria treatment guideline
Uk malaria treatment guideline
 
Tuberculosis summary
Tuberculosis summaryTuberculosis summary
Tuberculosis summary
 
Shock summary
Shock summaryShock summary
Shock summary
 
Stroke ( concise long case approach ) summary
Stroke ( concise long case approach ) summaryStroke ( concise long case approach ) summary
Stroke ( concise long case approach ) summary
 

Recently uploaded

Best medicine 100% Effective&Safe Mifepristion ௵+918133066128௹Abortion pills ...
Best medicine 100% Effective&Safe Mifepristion ௵+918133066128௹Abortion pills ...Best medicine 100% Effective&Safe Mifepristion ௵+918133066128௹Abortion pills ...
Best medicine 100% Effective&Safe Mifepristion ௵+918133066128௹Abortion pills ...
Abortion pills in Kuwait Cytotec pills in Kuwait
 

Recently uploaded (20)

Creating Accessible Public Health Communications
Creating Accessible Public Health CommunicationsCreating Accessible Public Health Communications
Creating Accessible Public Health Communications
 
Best medicine 100% Effective&Safe Mifepristion ௵+918133066128௹Abortion pills ...
Best medicine 100% Effective&Safe Mifepristion ௵+918133066128௹Abortion pills ...Best medicine 100% Effective&Safe Mifepristion ௵+918133066128௹Abortion pills ...
Best medicine 100% Effective&Safe Mifepristion ௵+918133066128௹Abortion pills ...
 
Unveiling Alcohol Withdrawal Syndrome: exploring it's hidden depths
Unveiling Alcohol Withdrawal Syndrome: exploring it's hidden depthsUnveiling Alcohol Withdrawal Syndrome: exploring it's hidden depths
Unveiling Alcohol Withdrawal Syndrome: exploring it's hidden depths
 
VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...
VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...
VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...
 
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS by Dr M.KARTHIK EMMANUEL
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS  by Dr M.KARTHIK EMMANUELCONGENITAL HYPERTROPHIC PYLORIC STENOSIS  by Dr M.KARTHIK EMMANUEL
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS by Dr M.KARTHIK EMMANUEL
 
Results For Love Spell Is Guaranteed In 1 Day +27834335081 [BACK LOST LOVE SP...
Results For Love Spell Is Guaranteed In 1 Day +27834335081 [BACK LOST LOVE SP...Results For Love Spell Is Guaranteed In 1 Day +27834335081 [BACK LOST LOVE SP...
Results For Love Spell Is Guaranteed In 1 Day +27834335081 [BACK LOST LOVE SP...
 
Tips to Choose the Best Psychiatrists in Indore
Tips to Choose the Best Psychiatrists in IndoreTips to Choose the Best Psychiatrists in Indore
Tips to Choose the Best Psychiatrists in Indore
 
TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...
TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...
TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...
 
Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...
Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...
Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...
 
Is Rheumatoid Arthritis a Metabolic Disorder.pptx
Is Rheumatoid Arthritis a Metabolic Disorder.pptxIs Rheumatoid Arthritis a Metabolic Disorder.pptx
Is Rheumatoid Arthritis a Metabolic Disorder.pptx
 
Premium ℂall Girls In Mumbai Airport👉 Dail ℂALL ME: 📞9833325238 📲 ℂall Richa ...
Premium ℂall Girls In Mumbai Airport👉 Dail ℂALL ME: 📞9833325238 📲 ℂall Richa ...Premium ℂall Girls In Mumbai Airport👉 Dail ℂALL ME: 📞9833325238 📲 ℂall Richa ...
Premium ℂall Girls In Mumbai Airport👉 Dail ℂALL ME: 📞9833325238 📲 ℂall Richa ...
 
TEST BANK for The Nursing Assistant Acute, Subacute, and Long-Term Care, 6th ...
TEST BANK for The Nursing Assistant Acute, Subacute, and Long-Term Care, 6th ...TEST BANK for The Nursing Assistant Acute, Subacute, and Long-Term Care, 6th ...
TEST BANK for The Nursing Assistant Acute, Subacute, and Long-Term Care, 6th ...
 
DR. Neha Mehta Best Psychologist.in India
DR. Neha Mehta Best Psychologist.in IndiaDR. Neha Mehta Best Psychologist.in India
DR. Neha Mehta Best Psychologist.in India
 
Tips and tricks to pass the cardiovascular station for PACES exam
Tips and tricks to pass the cardiovascular station for PACES examTips and tricks to pass the cardiovascular station for PACES exam
Tips and tricks to pass the cardiovascular station for PACES exam
 
Cas 28578-16-7 PMK ethyl glycidate ( new PMK powder) best suppler
Cas 28578-16-7 PMK ethyl glycidate ( new PMK powder) best supplerCas 28578-16-7 PMK ethyl glycidate ( new PMK powder) best suppler
Cas 28578-16-7 PMK ethyl glycidate ( new PMK powder) best suppler
 
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...
 
Making Patient-Centric Immunotherapy a Reality in Lung Cancer: Best Practices...
Making Patient-Centric Immunotherapy a Reality in Lung Cancer: Best Practices...Making Patient-Centric Immunotherapy a Reality in Lung Cancer: Best Practices...
Making Patient-Centric Immunotherapy a Reality in Lung Cancer: Best Practices...
 
Gallbladder Double-Diverticular: A Case Report المرارة مزدوجة التج: تقرير حالة
Gallbladder Double-Diverticular: A Case Report  المرارة مزدوجة التج: تقرير حالةGallbladder Double-Diverticular: A Case Report  المرارة مزدوجة التج: تقرير حالة
Gallbladder Double-Diverticular: A Case Report المرارة مزدوجة التج: تقرير حالة
 
Hemodialysis: Chapter 1, Physiological Principles of Hemodialysis - Dr.Gawad
Hemodialysis: Chapter 1, Physiological Principles of Hemodialysis - Dr.GawadHemodialysis: Chapter 1, Physiological Principles of Hemodialysis - Dr.Gawad
Hemodialysis: Chapter 1, Physiological Principles of Hemodialysis - Dr.Gawad
 
The Orbit & its contents by Dr. Rabia I. Gandapore.pptx
The Orbit & its contents by Dr. Rabia I. Gandapore.pptxThe Orbit & its contents by Dr. Rabia I. Gandapore.pptx
The Orbit & its contents by Dr. Rabia I. Gandapore.pptx
 

Guides on Gastroenterology

  • 1. Survival Guide: Gastroenterology Contents • What’s it all about? • Conditions you may be asked about in the first week • Abdominal pain • GI bleeding • Diarrhea • Gastroesophageal reflux disease • Do’s and Don’ts • History and physical examination Copyright © 2004 Elsevier
  • 2. What’s it all about? Gastroenterology is a subspecialty of internal medicine. It deals with conditions and diseases of the organs of the digestive tract and associated solid organs such as the pancreas, liver, and gallbladder. The most frequent complaints seen in the clinic and the hospital include abdominal pain, nausea, vomiting, diarrhea and GI bleeding. Management of gastrointestinal problems can be both medical and surgical. A key aspect of GI is learning to differentiate benign processes from those that are more serious and possibly needing a procedure or surgical intervention. Conditions you may be asked about in the first week The conditions you will usually be asked about in your first week are the more common complaints and diagnoses. The most important things you will be asked involve differential diagnoses, and how to work up the problem. The most common problems in gastroenterology include: • abdominal pain, • differentiating and working up a GI bleed, • diarrhea, and • gastroesophageal reflux disease. You may also come across other common conditions as you progress, such as: peptic ulcer disease, appendicitis, diverticulitis, colon cancer, hepatitis, cirrhosis, cholecystitis, pancreatitis, irritable bowel syndrome and inflammatory bowel syndrome. Abdominal pain PQRST • Presentation: ‘How?’ and ‘Where?’ • Quality: ‘Is the pain sharp, dull, burning, colicky?’ • Radiation: ‘Does the pain radiate anywhere (e.g. groin, back, shoulder)?’ • Severity: ‘How bad is the pain on a scale of 1 to 10?’, ‘What makes it better or worse?’ • Timing: ‘When does it occur?’, ‘How long?’, ‘Associations?’ The chronological sequence of events in the patient's history is often more important than emphasis on the location of pain. Careful attention should be paid to the extra-abdominal regions that may be responsible for abdominal pain. An accurate menstrual history in a female patient is essential. Abdominal examinations are mandatory in every patient with abdominal pain. Pelvic and rectal examinations are recommended in patients with lower abdominal pain especially if the pain is acute. Differential diagnosis Some causes of abdominal pain are obvious, some less so. It’s best to associate pain with quadrants. The following guidelines are meant to be general, because all disorders have been known to present atypically. • Right upper quadrant: Biliary colic, cholangitis, cholecystitis, pyelonephritis, renal colic, renal infarct, pneumonia, hepatic abscess, hepatitis, retrocecal appendicitis, pelvic inflammatory disease (PID).
  • 3. Left upper quadrant: Splenic infarct, pancreatitis, pyelonephritis, renal colic, renal infarct, pneumonia, PID. • Epigastric: Gastritis, gastric ulcer, duodenal ulcer, pancreatitis, carcinoma, pancreatic cancer, reflux esophagitis (sub-sternal pain). • Right lower quadrant: Appendicitis, ovarian cyst/torsion, ectopic pregnancy, salpingitis, urinary tract infection (UTI), renal colic, Crohn’s disease, colitis, cancer, PID. • Left lower quadrant: Diverticulitis, colitis, sigmoid volvulus, ovarian cyst/torsion, ectopic pregnancy, renal colic, UTI, PID. • Suprapubic: Appendicitis, diverticulitis, salpingitis, uterine fibroid, ovarian cyst, cystitis, PID. GI bleed The first step in working up a GI bleed is to assess your patient’s age: • patients under the age of 60 have a mortality of <1%; • patients over 80 have a mortality of >20% Check also for shock, renal disease, liver disease and cardiovascular disease (including hypertension) – these all increase the chances that your patient may die. Check your patient’s vital signs and make sure they are stable. Initial resuscitation requires restoration of intravascular volume, correction of coagulopathy and airway protection. Once it has been determined that the patient is stable, initial work-up includes nasogastric (NG) aspiration, rectal exam and Hemoccult, endoscopy and colonoscopy, barium studies, radionuclide imaging (this can detect a bleeding rate as low as 0.1 mL/min, but is only positive about 45% of the time) and angiography (a bleed must exceed 0.5 mL/min to be detected). Weigh up the significant pros and cons of each of the above. Upper GI bleeding • Hematemesis, melena > hematochezia, tachycardia, hypotension. • Evaluation: endoscopy if stable (this is urgent in patients with an active bleed and/or liver disease), NG tube and NG lavage. • Common causes: peptic ulcer disease, gastritis, esophageal varices, vascular abnormalities, Mallory-Weiss tear, neoplasm, esophagitis, stress ulcer. • Initial management: protect airway, stabilize with IV fluids, blood products. • Further management: endoscopy followed by therapy directed at underlying cause. Lower GI bleeding • Hematochezia > melena, but can be either. • Rule out upper GI bleed with NG tube and NG lavage, colonoscopy if stable. • Common causes: diverticulosis, arteriovenous malformations, colon cancer, inflammatory bowel disease, anorectal disease, mesenteric ischemia. • Initial management: stabilize patient with IV fluids, blood products if necessary. • Further management: rule out upper GI bleed; colonoscopy and management directed at underlying cause (eg. surgical resection of cancer, diverticula).
  • 4. Diarrhea Hx should include duration, frequency, estimated volume and consistency of each bowel movement, relation to meals, associated fever, pain, nausea, vomiting, blood in stool, history of travel, medication use. Major types of diarrhea are secretory, osmotic, exudative. • Secretory: Enterotoxins (Cholera, E. coli, S. aureus), gastric hypersecretion, laxative abuse. • Osmotic: Malabsorption. • Exudative: Shigella, Salmonella, C. difficile. Infection is the most common cause of diarrhea, and is usually caused by food poisoning. Initial workup includes CBC with differential, chemistry panel with BUN and creatinine. WBCs in stool indicate CHESS organisms: • Campylobacter. • Hemorrhagic E. coli. • Entamoeba histolytica. • Salmonella. • Shigella. Treatment consists of correction of fluid and electrolyte abnormalities and reduction of symptoms. Avoid antibiotics in enteric salmonella infection because a prolonged carrier state may be induced. Antimotility agents should be used cautiously with inflammatory diarrhea. Gastroesophageal reflux disease Gastroesophageal reflux disease is symptomatic reflux of gastric contents into the esophagus. It is one of the most common conditions you will see . Symptoms include heartburn, chest pain, regurgitation, belching, dysphagia, and halitosis. Additional pulmonary symptoms including chronic cough, hoarseness, wheezing and asthma. If you see a patient who complains of chronic tickle in the back of the throat with associated cough, consider gastroesophageal reflux disease after ruling out other possibilities. Ask your patient whether pain wakes them up at night—this generally is NOT reflux and more likely associated with ulcer disease. Risk factors include smoking, drinking alcohol, eating chocolate or mints, hiatal hernia, obesity, increased intra-abdominal pressure, and increased plasma progesterone levels. Diagnosis is usually based on history. • Barium swallow: least sensitive test. • 24hr pH monitoring: gold-standard for measuring GERD (pH <4). • Manometry: may detect transient lower esophageal sphincter (LES) relaxation, hiatal hernia. • Esophagogastroduodenoscopy (EGD) with biopsies, if patient has long-standing symptoms – to rule out Barrett’s esophagus and adenocarcinoma. • Acid-perfusion test (Bernstein test) can be done but is becoming less common.
  • 5. Treatment includes lifestyle changes, drug management and surgery. • Lifestyle: weight loss, elevate head of bed, avoid certain foods. • Drugs: antacids, H2-receptor antagonists or proton pump inhibitors (PPIs). • Surgery: nissen fundoplication if refractory or severe disease. Complications include ulceration, strictures, upper GI bleeding, aspiration and risk of pneumonia, Barrett’s esophagus (which may lead to adenocarcinoma of the esophagus). Do’s and Don’ts • ALWAYS remember to ask women about their menstrual cycle and sexual activity since many gynecological and obstetrical conditions can mimic GI complaints. • Do perform a rectal exam in association with Hemoccult. No-one likes having a rectal exam, but it is almost always pertinent, especially when ruling out GI bleeding. History and physical examination Ask about bowel habits and any changes in them, flatus, nausea, vomiting, dark or tarry stools, and association of symptoms with eating or types of food. Ask the patient to point to the location of the pain before initiating the exam. • Inspect the abdomen, particularly noting the contour, any scars and locations, and noticeable masses or bulges. • Listen for bowel sounds as well as abdominal aortic and renal bruits. • Percuss the abdomen; tympanic abdomen suggests obstruction. • Always start palpation away from areas of pain. • Do light palpation followed by deeper palpation; note any masses or muscle rigidity (“guarding”). Percussion is also a good way to test for “rebound” tenderness or acute abdomen. Some physicians may try to bump the bed or exam table to assess for peritoneal inflammation, as well as asking their patient to cough or just percuss the abdomen; these will usually elicit “rebound” as well. BUT always consider your patient’s comfort – testing for rebound causes additional pain and you should make sure that it is absolutely necessary. Author By Matthew Reinersman, Southern Illinois University School of Medicine.