This document provides information on jaundice and diarrhea. It discusses the causes, classifications, evaluations, and approaches to patients with jaundice and chronic or acute diarrhea. Jaundice is caused by increased bilirubin levels and can be unconjugated or conjugated. Diarrhea is classified as acute infectious, chronic, or motility disorders based on duration and etiology. Evaluations include history, physical exam, and lab tests.

1. SYMPTOMATOLOGY IN
GIT PART-11
DR.MUZAMIL JAMIL
ASSOCIATE PROFESSOR
MEDICINE

2. JAUNDICE
♦ Accumulation of bilirubin.
♦ Yellowish pigmentation of plasma.
♦ Discolouration of heavily perfused tissues
likeskin,sclera and mucous membranes.
♦ Clinically hyperbilrubinemia manifests as
icterus or jaundice.
♦ Serum bilrubin > 34-43 micro mol/l
♦
2.6-2.5 mg/dl

3. ♦ Jaundice manifestes even at lower levels in people
with fair skin and anemia
♦ Obscured in dark skin individuals or with edema.
♦ Need to be observed in sun light.
♦ Needs to be differentiated from Carotenemia
charecterised by yellow brown pigmentation of
palms ,soles and nasolabial folds with normal
sclera ,mucosal membrane and urine color.

4. Production and metabolism
♦ Normal serum Bilirubin Conc.
5-17 micro mol/l
.3-1 mg/l
♦ More than 90% is unconjugated circulating
as albumin bound complex.
♦ Remainder conjugated(primarily
glucuronide) to polar group which is water
soluble and excreted in urine.

5. ♦ 80% of Bilirubin –RBCs break down.
♦ 15-20%-Ineffective erythropoises and
metabolism of other heme containing
protiens

6. Metabolism
♦ Hepatic uptake.
♦ Conjugation.
♦ Excretion into bile.

7. Derangement of bilirubin
metabolism
♦ Over production .
♦ Decreased hepatic uptake.
♦ Decreased hepatic conjugation.
♦ Decreased excretion.

8. Pathological terms.
♦ Hemolytic.
♦ Hepatocellular.
♦ Obtructive.

9. Classification
♦ Predominantly unconjugated
1-Over production
A)Hemolysis
B)Ineffective erythropoises.
2-Decreased hepatic uptake.
A)Prolonged fasting.
B)Sepsis.

10. ♦ 3-Decreased conjugation.
(decreased glucoronyl transferase)
A)Hereditary
Transferase deficiency
.
Gilbert syndrome.
. Crigler Najjar syndrome.
B)Neonatal jaundice.
C)Acquired
transferase deficiency
Drugs
inhibition –Choramphenical

11. ♦ Breast milk jaundice.
♦ Hepatocellular disease.
♦ 4-Sepsis.

12. Predominantly conjugated
hyperbilirubinema.
♦ 1.Impaired hepatic excreation
A.Familial or hereditary.
Dubin jhonson &Rotor
syndromes,
Recurrent benign
intrahepatic cholestasis, Cholestatic
jaundice of pregnancy.
B.Acquired disorders.
1)Hepatocellular diseases
Hepatitis,cirrhosis.
2)Drugs.
OCP,
Androgens,Chloramphenical.

13. ♦ 3)Alcohol
4)Sepsis
5)Post operative
6)Biliary
cirrhosis.
♦ Extrahepatic Biliary obstruction.
Intraductal
Compression of biliary
duct.
–

14. Evalution of jaundice.
Hyperbilirubinemia.
♦ Hemolysis—In direct Bilirubin.
♦ Hepatobiliary –Direct Bilirubin.

15. Unconjugated Hyperbilirubinia.
♦ Hemolysis.
♦ Resorbtion of large hematoma.
♦ Bil. Rarely above 5mg%.
♦ Gilbert syndrone is an exception.
♦ Reticulocyte count is high.
♦ Hb is low.
♦ LDH is high.

16. Conjugated Hyperbilirubinia
Hepatocellular.
Intrahepatic obstruction.
Extra hepatic obstruction.

17. Approach to patient with
jaundice.
♦ Age.
Young------- Hepatitis.
Old -------Malignancy.
♦ Duration of symptoms.
♦ Abdominal pain.
♦ Fever and other symptoms of active
inflammation.
♦ Appitite change,weight loss or altered
bowels—Malignancy.

18. ♦ Transfusion.(hepatitis B&C).
♦ Use of intravenous drugs.
♦ Sexual contact.
♦ Ethanol.
♦ Travel and immunization.
♦ Drugs.
Cholestsis.Anabolic steroids and chlorpromazine.
Heepatocellular
necrosis. Acetoaminophen,ATT.

19. ♦ Sore throat and rash—
Infectious mononucleosis.
♦ Pruritis—Chronic cholestasis.
Hepatic: Primary Biliary cirrhosis.
.
Sclerosing cholangitis.
Extra hepatic obstruction.
♦ Acholic stools.
♦ Pregnancy.

20. ♦ Past history of jaundice, hepatitis,arthralgias
Prodromal symptoms.
Viral hepatitis.
♦ Previous surgery:Biliary procedures.
.
Stones,strictures.
♦ Pre existing IBD.
♦ Right heart failure.
♦ Skin tatooing.
♦ History of GI bleeding.
♦ Family history.Congenital spherocytosis.

21. Physical examination.
♦ Excoriation.
♦ Fever and epigastric/RUQ tenderness.
♦ Painless jaundice.
♦ Enlarged tender liver.
♦ Rapidly enlarging liver.
♦ Palpable gall bladder.
♦ Spleenomegaly.

22. ♦ Peripheral stigmas of liver diasease.
♦ Wasting and lymphoadenopathy.
♦ History pointing to malignancy.
Primary tomours in abdomen ,breast
and thyroid should be looked for.

23. Diarrhea.
♦ Increase in daily stool weight of more than
250gm/24 hours.
♦ Normal bowel frequency ranges between
3times/day to3times/week.

24. Factors influencing stool
weight ,consistency and
frequency. in diet.
♦ 1.fiber content
♦ 2.Gender.
♦ 3.Ingested medicines.
♦ 4.Exercise.
♦ 5.Stress.

25. ♦ Pseudodiarrhea:
Increased frequency with normal
weight.
IBS ,Proctitis and
Hyperthyroidism.
♦ Incontinence:
Involuntary release of rectal contents.

26. Acute and choronic.
♦ Acute: 7---14 days.
occasionally less than 6 week.
♦ Chronic: More than 4 weeks.
Occasionally more than 6
weeks.
♦ Persistent:2—4 weeks.
♦ Acute infectious causes are commonest.
♦ Acute GI diseases are second only to URTI.

27. Epidemiology.
♦ In less than 5 years of age.
2—3 illnesses per child per
year.Developed countries.
10—
18 illnesses per child per year in developing
countries.
One
Billion cases world wide.
4—6 million deaths.
12600 Deaths/Day.

28. Acute infectious diarrhea.
♦ Non-inflammotry.
♦ Inflammotry.
.
NON-INFLAMMOTRY
♦ Watery.
♦ Non bloody.
♦ Periumblical cramps.
♦ Bloating.
♦ Nausea and vomitting .
♦ Single or in combition.

29. Inflammatory diarrhea
♦ Fever.
♦ Bloody.
♦ Small in volume.
♦ Left lower quadrant cramps.
♦ Urgency and tenesmus.

30. Etiology(non-inflammatory)
♦ Viral:Norwalk,Nor walk like and Rota virus
♦ Protozoal: Giardia,cryptosporidium.
♦ Bactrial:
1.Preformed toxins:Styphylococcus
aures, bacellius cereus and clostridium
perfringens 2.Enterotoxin production:Ecoli,vibrio cholera.

31. Food poisoning
♦ Staphylococcus aureus.
♦ Shortest incubation period.1—6 hours.
Lasts
for less than 12 houres.
♦ Infected human carriers are the source.
♦ If food is left to cool slowly and remains at room
temperature organisms have opportunity to form
toxins.
♦ Out breaks after picnics.
♦ Potatos,salads,mayonnise,cream pastries.

32. Bacillus cereus.
♦ Short incubation period.
1—6 hours emetic form.
Long
incubation period.
upto 18
hours diarrheal form.
♦ If cooked rice is not refrigerated,heat
resistant spores which have escaped boiling
germinate and produce toxin.Frying before
serving may not destroy these preformed
heat stable toxins.

33. Clostridium perferingens
♦ Incubation period 8—14 hours.
♦ Heat resistant spores.
♦ Inadequately cooked meat, poultry or
legumes.
♦ self limiting upto 24 hours.

34. Etiology for infllammatory
diarrhea.
♦ Viral:CMV.
♦ Protozoal:Entamoeba histolytica.
♦ Bacterial:Shigella,salmonella,compylopacte
r jejuni,entero invasive E-coli and vibrio
parahemolytic.

35. Approach to patient.
♦ HISTORY:
1.Duration.
2.Fever.Infections out side
the gut like malaria.
3.Frequency.May correlate
with dehydration.
4.Abdominal pain.
-Inflammatory
nature.
-RIF
Pain with yersina.
-Bloating with Giardiasis.

36. ♦ 5.Vomiting.
-Acute illness
-Toxin.
-Systemic disease.
-Obstruction.
♦ 6.Tenesmes:shigellosis.
♦ 7.Appearance of stools.
-Blood—Shigellosis.

37. ♦ -Rice watery—Vibrio cholera.
-Bulky white—small intestine.
♦ 8.Common source.
♦ 9.Antibiotic use.
♦ 10.Travel.

38. Physical examination.
♦ Signs of dehydration—Severity of illness.
♦ MILD.
-Thirst.
-Dry mouth.
-Decreased axillary sweat.
-Decreased urine out put.
-Slight weight loss.

39. Moderate dehyderation.
♦ Orthostatic hypotension
♦ Skin tenting.
♦ Sunken eye balls.

40. Severe dehydration.
♦ Hypotension.
♦ Tachycardia.
♦ Confusion.
♦ Frank coma.

41. Prompt medical evaluation.
♦ Inflammatory diarrhea.
♦ High fever.
♦ Bloody diarrhea.
♦ Abdominal pain.
♦ 6 or more unformed stools/24 hours.
♦ Profuse watery diarrhea.
♦ Severe dehyderatuon.
♦ Elderly or immunocompromised patients.

42. Chronic diarrhea.
Diarrhea which persists for more than 4
weeks
Needs evaluation to exclude serious
pathology
Most of the causes are noninfectious.

43. Classification.
♦ 1-Osmotic.
♦ 2-Secreatary.
♦ 3-Inflammatory.
♦ 4.Motility disorders.
♦ 5.Fectitious.
♦ 6.Malabsorptive conditions.
♦ 7.chronic infections.

44. Osmotic diarrhea.
♦ Results from lack of absorption of orally
ingested solutes (food).Osmotic effect.
♦ Relieved with fasting.
♦ Clinical symptoms are usually becauses of
malabsorption of fat or carbohyderates.
♦ Osmotic causes include lactase deficiency,
drugs like laxatives etc.

45. Steatorrheal causes.
♦ Intraluminal maldigestion.
.Chronic pancreatitis.
.Decreased bile salts.
.Bacterial over
growth.
♦ Mucosal malabsorption.
.Celiiac
disease.
.Tropical sprue.

46. Secreatary diarrhea.
♦ Excreation of large ammount more than
1 litre/day.
♦ No effect with fasting.
♦ Abnormal fluid and electrolyte transport.
♦ Harmones mediated.
♦ Causes may include Carcinoid, Zollinger
ellison syndrome, Medullary carcinoma of
thyroid and extensive gut recsection.

47. Inflammatory diarrhea.
♦ Fever.
♦ Abdominal pain and tenderness.
♦ Hematochezia.
♦ Patients may have toxic looks.
♦ Extra intestinal manefestation may be
present.
♦ Causes include IBD,malignancy,radiation
enterits.

48. Motility disorders
♦ Systemic disorders like diabetes and
hyperthyroidism.
♦ Previous gut surgery.
♦ Irritable bowel.
♦ Fecal impaction.
♦ Neurological disorders.
♦ FECTITIOUS DIARRHEA:Laxative abuse

49. Approach to patients.
♦ History.
♦ Symptoms and signs of inflammation.
♦ Extra intestinal manefestations.
♦ Perepheral edema or ascitis.
♦ Type of stools-intestinal malabsoption.
♦ Flatulence.
♦ Weight loss.

50. ♦ Systemic manifestations like flushing.
♦ Autonomic dysfunctions like postural drop
and disordered sweating in diabetes.
♦ Diarrhea alternating with constipation-IBS.
♦ Effects of malabsorption like anemia,
bleeding tendency,osteopenia,amenorrhea
and infertility should be looked for.

51. Common causes
♦ Abdominal tuberculosis.
♦ Coeliac disease.
♦ Inflammatory bowel disease.
♦ Giardiasis.
♦ Tropical sprue.
♦ Colonic malignancy.