Introduction to GI Medicine.... By Shapi.pdf

INTERNAL MEDICINE
• GASTRO-INTESTINAL SYSTEM
• INTRODUCTION TO GIT MEDICINE
Dr. Chongo Shapi (BSc.HB, MBChB).
Medical Doctor
5 March 2024 1
Dr. Chongo Shapi (BSc. HB, MBChB)

SOME COMMON DEFINITIONS
• Leucoplakia: Is an oral mucosal white patch
that will not rub off and is not attributable to
any other known disease. It is a premalignant
lesion, with a transformation rate, which
ranges from 0.6% to 18%. Oral hairy
leucoplakia is a shaggy white patch on the side
of the tongue seen in HIV, caused by EBV.
5 March 2024 Dr. Chongo Shapi (BSc. HB, MBChB) 2

CONT’
• Aphthous ulcers: 20% of us get these shallow, painful ulcers on the
tongue or oral mucosa that heal without scarring. Causes of severe
ulcers include Crohn’s and coeliac disease; Behçet’s ; trauma;
erythema multiforme; lichen planus; pemphigus; pemphigoid;
infections (herpes simplex, syphilis, Vincent’s Angina.
• Minor ulcers: avoid oral trauma (eg hard toothbrushes or foods
such as toast) and acidic foods or drinks. Tetracycline or
antimicrobial mouthwashes (eg chlorhexidine) with topical steroids
(eg triamcinolone gel) and topical analgesia. Severe ulcers: possible
therapies include systemic corticosteroids (eg oral prednisolone 30–
60mg/d PO for a week) or thalidomide (absolutely contraindicated
in pregnancy).
• Biopsy any ulcer not healing after 3 weeks to exclude malignancy;
• refer to an oral surgeon if uncertain.

CONT’
• Candidiasis (thrush): Causes white patches or
erythema of the buccal mucosa. Patches may be
hard to remove and bleed if scraped.
• Risk factors: Extremes of age; DM; antibiotics;
immunosuppression (long-term corticosteroids,
including inhalers; cytotoxics; malignancy; HIV).
• Treat with: Nystatin suspension 400 000U (4mL
swill and swallow/6h). Fluconazole for
oropharyngeal thrush.

CONT’
• Cheilitis (angular stomatitis): Fissuring of the
mouth’s corners is caused by denture
problems, candidiasis, or deficiency of iron or
riboflavin (vitamin B2)
• Gingivitis Gum inflammation ± hypertrophy
occurs with poor oral hygiene), drugs
(phenytoin, ciclosporin, nifedipine),
pregnancy, vitamin C deficiency (scurvy),
acute myeloid leukaemia or Vincent’s angina.

CONT’
• Microstomia: The mouth is too small, eg from
thickening and tightening of the perioral skin
after burns or in epidermolysis bullosa
(destructive skin and mucous membrane blisters
± ankyloglossia) or systemic sclerosis.
• Macroglossia: The tongue is too big. Causes:
myxoedema; acromegaly; amyloid. A ranula is a
bluish salivary retention cyst to one side of the
frenulum, named after the bulging vocal pouch of
frogs’ throats (genus Rana).

CONT’
• Glossitis: Means a smooth, red, sore tongue,
eg caused by iron, folate, or B12 deficiency If
local loss of papillae leads to ulcer-like lesions
that change in colour and size, use the term
geographic tongue (harmless migratory
glossitis).

SOME COMMON INVESTIGATIONS
• Sigmoidoscopy: Views the rectum + distal colon (to
splenic flexure). Flexible sigmoidoscopy has largely
displaced rigid sigmoidoscopy for diagnosis of distal
colonic pathology, but 25% of cancers are still out of
reach. It can be used therapeutically, eg for
decompression of sigmoid volvulus.
• Preparation: Phosphate enema PR.
• Procedure: Learn from an expert; do PR exam first. Do
biopsies—macroscopic appearances may be normal, eg
IBD, amyloidosis, microscopic colitis.

CONT’
• Colonoscopy: Preparation: Stop iron 1wk prior;
discuss with local endoscopy unit bowel
preparation and diet required. Procedure: Do PR
first. Sedation and analgesia are given before
colonoscope is passed and guided around the
colon.
• Complications: Abdominal discomfort;
incomplete examination; haemorrhage after
biopsy or polypectomy; perforation (<0.1%).
• Post-procedure: no alcohol, and no operating
machinery for 24h.

CONT’
• Upper GI endoscopy Indications: Pre-procedure: Stop PPIS 2wks
preop if possible (reduces pathology-masking). Nil by mouth for 6h
before. Don’t drive for 24h if sedation is used. Procedure: Sedation
optional, eg midazolam 1–5mg slowly IV (to remain conscious; if
deeper sedation is needed, propofol via an anaesthetist (narrow
therapeutic range)); nasal prong O2 (eg 2L/min; monitor
respirations & oximetry). The pharynx may be sprayed with local
anaesthetic before the endoscope is passed.
• Continuous suction must be available to prevent aspiration.
Complications: Sore throat; amnesia from sedation; perforation
(<0.1%); bleeding (if on aspirin, clopidogrel, warfarin, or DOACS
these need stopping only if therapeutic procedure).
• Duodenal biopsy: The gold standard test for coeliac disease, also
useful in unusual causes of malabsorption, eg giardiasis, lymphoma,
Whipple’s disease.

CONT’
• Liver biopsy Route: Percutaneous if INR in range else trans jugular with
FFP. Indications: Elevated LFT of unknown aetiology; assessment of fibrosis
in chronic liver disease (this indication being replaced by ultrasound-based
elastography); suspected cirrhosis or suspected hepatic lesions/cancer.
Pre-op: Nil by mouth for 8h. Are INR <1.5 and platelets >50 ≈ 109/L? Give
analgesia. Procedure: Sedation may be given.
• Do under US/CT guidance; the liver borders are percussed and where
there is dullness in the mid-axillary line in expiration, lidocaine 2% is
infiltrated down to the liver capsule. Breathing is rehearsed and a needle
biopsy is taken with the breath held in expiration.
• Afterwards lie on the right side for 2h, then in bed for 4h; check pulse and
• BP every 15 mins for 1h, every 30 mins for 2h, then hourly until discharge
4h postbiopsy.
• Complications: Local pain; pneumothorax; bleeding (<0.5%); death
(<0.1%).

Thanks

Introduction to GI Medicine.... By Shapi.pdf

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