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MEDICAL UNIVERSITY
Propaedeutics of Internal
Diseases Department
Professor T.A. Dronova
Lecture
GASTROENTEROLOGY
MAIN CLINICAL SYNDROMES
blood lost
GASTROENTISTINAL BLEEDING
Hematemesis - vomiting of blood (bright red or
coffee ground)
Melena - tarry black, sticky, foul smelling stool
(other stool darkness - iron & bismuth )
Special features:
a) approximately 60 ml of blood is required to
produce single black stool
b) the blood loss > 60 ml produces melena for
more than 7 days
c) to produce melena the blood must be in the
gut for 8 hours
Etiology
Common causes
Chronic duodenal ulcer
Chronic gastric ulcer
Gastric erosions (erosive gastritis)
Varices
Mallory-Weis tear
Esophagitis
Duodenal erosions
Stomach cancer
Miscellaneous
%
25
20
20
10
7
5
5
3
5
heartburn history
Gastric erosions NSAIDs or
corticosteroids using
Liver cirrhosis signs of chronic liver
diseases (jaundice, palmar erythema,
leukonychia, spider nevi,
hepatosplenomegaly & ascites)
Mallory-Weis syndrome - history of
forceful vomiting before hematemesis
Clinical features
Bleeding from upper GIT may present with
Severe bleeding
Symptoms:
weakness, faintness, nausea, sweating,
restlessness & disorientation
Signs:
postural hypotension > 10 mmHg - indication
of > 20% of blood volume lost
rapid pulse rate
decreased urinary output
patient may be in shock on arrival (systolic BP
< 90 mm Hg)
bleeding
BP, pulse & postural changes (orthostatic drop
in blood pressure > 10mm Hg or pulse rise of
20 beats per minute or more indication of 1520% acute lost of blood volume)
Urine output monitoring (acute renal failure
due to hypovolemia)
Shock on arrival ( systolic BP < 90mmHg )
indication of massive 20-25% acute volume lost
(severe emergency)
Investigations
Endoscopy
Selective abdominal angiography
Urea, creatinine, electrolytes
Liver function tests, protrombin
Blood grouping & cross matching
Blood test
Radionuclide scan
Emergency management
History & examination
Pulse & BP monitoring half-hourly
Blood examination for hemoglobin, urea, cretinine,
diverticulosis, angiodysplasia
Bleeding with pain - in anal fissure, ischemic
colitis & inflammatory bowel disease
Haematochezia - bright red blood from
rectum:
bleeding from anal & rectal lesions in
hemorrhoids, fissures, fistulas & carcinomas
amount of blood vary from few drops to
massive bleeding
Haematochezia
It is a passage of red (or maroon) blood from
COLONIC DISEASE
Rectal bleeding
Diagnostic stool appearance:
Blood coating exterior of formed stool - lesion in
1.
2.
3.
4.
5.
Physical examination
in colonic diseases
Digital rectal examination (perianal,
electrocoagulation of angiodysplasia
Intra-arterial vasopression or embolization
(90% effective in diverticulum or
angiodysplasia)
Surgery
Blood in stool
Blood mixed with stool: left sided colonic
Upper
gastrointestinal
bleeding
Lower
gastrointestinal
bleeding
Site
Above Treits
Below Treits
ligament (esophagus, ligament (small
stomach, duodenum) intestine & colon)
Presentation
Hematemesis
Cofee ground
vomiting
Melena
Hematochezia
Upper
gastrointestinal
bleeding
Nasogastric Blood
aspiration
Bowel
sounds
Hyperactive
Lower
gastrointestinal
bleeding
Clear fluid
Normal
MALABSORPTION
Malabsorption - inadequate transport of one
Nutrient absorption
Sites
Nutrient absorption
Physiology - 3 phases
Luminal phase: hydrolysis &
solubilization of nutrients
Mucosal phase: further breakdown of
nutrients & transfer into cell
Transport phase: removal of nutrients
into vascular or lymphatic circulation
1. Intraluminal malabsorption
Disoders
Pancreatic insufficiency:
Chronic pancreatitis
Cystic fibrosis (autosomal disease)
Carcinoma of pancreas
Deficiency of bile acids:
Enterohepatic circulation interruption (resection or
terminal ileum disease)
Small intestine colonization with bacteria which
deconjugate bile acids (stagnant loop syndrome)
Uncoordinated gastric emptying:
Gastroenterostomy
Partial gastrectomy
abnormal mucosa):
Coeliac disease (gluten-sensitive enteropathy)
Tuberculosis
Tropical sprue
Lymphoma
Radiation enteritis
Whipples disease (macrophages infiltration)
Malabsorption of specific substances (histologically
normal mucosa):
Lactase deficiency
infiltrations
Malabsorption Syndrome
Symptoms
GIT system
Genitourinary system
Hematopoetic system
Musculoskeletal system
Nervous system
Skin
MALABSORPTION
Nutritional
deficiencies
Features
Fats
Steatorrhea, frothy
stools, watery diarrhea,
weight loss
Carbohydrates
Flatulent dyspepsia
(borborygmus),
abdominal distension,
flatus, watery diarrhea
MALABSORPTION
Nutritional
Features
deficiencies
Protein Weight loss, muscle wasting,
hypoalbuminuria, oedema,
leuconychia
Folic acid Macrocytic,
megaloblastic anemia,
glossitis, oral mucosa
ulceration in folic acid
deficiency
MALABSORPTION
Nutritional Features
deficiencies
Vitamin B12 Macrocytic, megaloblastic
anemia, glossitis, mental
& neurological
disturbances
Vitamin B
complex
Cheilosis, angular
stomatitis, dermatitis,
polyneuritis
MALABSORPTION
Nutritional
deficiencies
Features
Vitamin C
Bleeding tendency
Vitamin A
Follicular
hyperkeratosis,
xeropthalmia, night
blindness
MALABSORPTION
Nutritional
deficiencies
Features
Vitamin D &
Calcium
Osteomalacia
(rickets), proximal
myopathy,
paraestesia, tetany
Vitamin K
Purpura,
hemorrhages
(bruising & bleeding)
MALABSORPTION
Nutritional
deficiencies
Features
Iron
Hypochromic anemia,
cheilosis, spoon-shaped
nails (koilonychia),
apthous ulcers
Sodium
Muscular weakness,
cramps
MALABSORPTION
Nutritional
deficiencies
Features
Potassium
Flaccidity,
arrhythmias
Magnesium
Muscular weakness,
paraestesia, tetany
Water
Nocturnal diuresis
MALABSORPTION
Nutritional
deficiencies
Features
Zinc
Bile salts
Watery diarrhea
Clinical features
days ago
constipation is alternated with diarrhea
through irritation of the small intestine by
fermented food discharged into it from the
pylorus that is opened by intensified
peristalsis
alkalosis develops if large amount of HCl is
lost in vomiting
Clinical features
Investigation
Investigation
Endoscopy:
Lesion at pylorus
Increase in fasting residue of stomach
food
Serum electrolytes depletion
INTESTINAL OBSTRUCTION
2 types of intestinal obstruction
Simple or dynamic: peristalsis working
against obstruction agent in the intestinal
lumen, in the wall or outside the wall (fecal
impaction, stricture or adhesion)
Strangulation or adynamic: peristalsis ceases
& no propulsive wave occurs - with intestinal
blood supply when the bowel is trapped or
twisted (paralytic ileus or mesenteric vascular
occlusion)
INTESTINAL OBSTRUCTION
Etiology
Luminal
obstruction
Fecal impaction
Gallstone ileus
Worms (ascaridiasis)
Intrinsic
lesions of
bowel wall
Exstrinsic
compression
Adhesion
Hernias
Volvulus
INTESTINAL OBSTRUCTION
Clinical features
Pain:
Colicky pain in mechanical obstruction
Dull constant pain in paralytic ileus
Vomiting:
Copious in high small bowel
obstruction
Late or absent in lower small bowel or
colon obstruction
INTESTINAL OBSTRUCTION
Clinical features
Abdominal distention
Distention confined to some loops of bowel ridges across the abdomen forming Ladder
Pattern - visible intestinal peristalsis - distal
small bowel obstruction: step ladder form of
peristalsis waves (motile small intestine) in
umbilical region
Later diffuse distention indication of chronic
large bowel obstruction or paralytic ileum
Complete obstruction - feaces & flatus not
passed
First - increased bowel sounds, later - absent
peristaltic sounds
INTESTINAL OBSTRUCTION
Investigation
Finger examination of rectum:
INTESTINAL OBSTRUCTION
Management
Nothing per os
Decompression (gastrointestinal drainage
via nasogastric tube)
IV fluid & electrolytes
Antibiotics
Surgery
ACUTE ABDOMEN
ACUTE ABDOMEN a term used to
ACUTE ABDOMEN
CAUSES
Bowel
Acute appendicitis
Perforated peptic ulcer or abdominal viscus
Diverticular disease
Intestinal obstruction & strangulation
Meckels diverticulum
Terminal ileitis (Yersinia infection)
ACUTE ABDOMEN
CAUSES
Vascular
Acute vascular insufficiency
Ruptured aortic aneurysm
Gynecological
Ruptured ectopic pregnancy
Ruptured ovarian cyst
Acute salpingitis
ACUTE ABDOMEN
CAUSES
Others
Cholecystitis
Acute pancreatitis
Acute mesenteric adenitis
Medical causes of abdominal pain
ABDOMINAL PAIN
MECHANISMS
1. Visceral pain
a) Irritation or inflammation of peritonium
(peritonitis, pancreatitis)
b) Vascular insufficiency (strangulation of bowel
in hernia or volvulus, acute mesenteric vascular
obstruction)
c) Spasm of hollow viscus (intestinal colic, biliary
colic, ureteric colic)
d) Stretching of capsule of solid organs (liver,
spleen & kidney when they become enlarged)
e) Ulceration of tissue (peptic ulcer)
ABDOMINAL PAIN
MECHANISMS
2.
Referred pain
Miscellaneous
ACUTE ABDOMEN
Clinical picture
Paroxysm of severe abdominal pain
Peritoneal irritation signs (respiratory abdomen
External localization
on abdominal wall
Stomach &
duodenum
Epigastrium, midline
or slightly to the right
External localization
on abdominal wall
Right colon
Left colom
External localization
on abdominal wall
Rectosigmoid
Suprapubic
Bladder
Suprapubic
External localization
on abdominal wall
Rectum
Gallbladder
Midepigastric,
radiating to right
upper quadrant & to
right scapular area
External localization
on abdominal wall
Midepigastric,
radiating to shoulder
or retrosternally to
neck
Pancreas
Midepigastric,
spreading laterally to
back if posterior
peritoneum is
involved
ACUTE ABDOMEN
Clinical picture
History
1. Pain
Onset: sudden in perforated duodenal ulcer &
ACUTE ABDOMEN
Clinical picture
Tongue furred in most acute abdominal
disease
Temperature fever more common in
acute inflammatory conditions
ACUTE ABDOMEN
Clinical picture
Examination
a) Signs of peritonitis
Site of tenderness
Guarding localized or generalized
Rebound tenderness
b) Signs of obstruction
Distension of abdomen due to gas
Increased gut sounds (borborygmi)
Absent gut sounds suggest peritonitis
ACUTE ABDOMEN
Investigations
Pelvic & rectal examination
Pelvic examination for gynecological disorders
ACUTE ABDOMEN
Investigations & treatment
Hospitalization
Hourly taking body temperature
Total blood counts
ECG
Radiographic abdomen examination (R-scopy &
R-graphy)
Surgery
ACUTE APPENDICITIS
SYMPTOMS
Pain begins as vague, central abdominal pain
ACUTE APPENDICITIS
SIGNS
1. Fever: low grade fever (100*F)
2. White & furred tongue
3. Tenderness in right iliac fossa
4. Localized guarding over the
inflamed appendix
ACUTE APPENDICITIS
Confirmatory signs
1) Rovsing's sign:- Pressure on the left iliac
ACUTE APPENDICITIS
INVESTIGATIONS & TREATMENT
INVESTIGATIONS
Blood CP:- Shows leucocytosis (only
during 1 hour
Formula: D ( HCl ) = A X B X 0.0365
D ( HCl ) - debit-hour of HCl
A - amount of gastric juice secreted in 1 hour
B - acidity of gastric juice in titrating units
0.0365 - molecular weight of HCl
Normal BAO level ranges from 50-150 mg HCL
& normal MAO level - from 200-400 mg HCl
juice amount
Gastric hyperacidity or hyperchlorhydria excessive gastric acidity
Hypersecretion: gastric juice > 160 ml extracted
in 1 hour during examination with thin tube
Hypersecretion manifested by constant
effusion of gastric juice containing free HCl:
amount of content in fasting stomach > 70 ml
(associated with complaints of heartburn,
vomiting & hunger pain)
content
Gastric pH-metry
Normal pH in esophagus - neutral or slightly
alkaline (7,0-7,2)
Normal pH in stomach:
cardia = 1,3-2,0
antrum >2,5
0,9-1,3 hyperacidity
2,0-3,0 moderate hypoacidity
3,0-5,0 significant hypoacidity
> 6,0 veritable achlorhydria
Gastric pH-metry
After ingestion of 0.5 mg of NaHCO3,
INADEQUATE DIGESTION
SYNDROME
Upset cavital digestion: stomach &
intestinal dyspepsia
Upset parietal digestion
Mixed form
DYSPEPSIA - term used as collective
description for variety of
alimentary symptoms
Dyspepsia
SYMPTOMS INCLUDED IN TERM DYSPEPSIA
Upper abdominal pain (may or not be related to
food)
Gastro-oesophageal regurgitation & heartburn
Anorexia, nausea & vomiting
Early repletion or satiety after meals
A sense of abdominal distension or bloating
(sense of abdominal distension)
Flatulence (burping, belching) & aerophagy
Dyspepsia
Etiology
Non-compensated secretory stomach
insufficiency
Exocrine pancreas dysfunction
Upset bile secretion
Disordered chyme passage through GIT:
stasis, stenosis, intestinal compression,
intense peristalsis accelerated passage
Intestinal infection & dysbacteriosis
Alimentary disorders (overeating, diet rich in
protein, fat, carbohydrate)
Dyspepsia
Most common causes
Stomach disorders (atrophic gastritis with
Dyspepsia
Pathogenesis
Incomplete breakdown of food particles
Active propagation of intestinal bacterial flora
Dysbacteriosis
Functional dyspepsia - psychological factors
Gastric Dyspepsia
Etiology
Dyspepsia - commonly associated with
Gastric Dyspepsia
Clinical picture
Feeling of discomfort
Epigastrium pressure or distension after meals
Frequent eructation
Regurgitation (often with acid or fetid odor)
Unpleasant taste in mouth
Nausea
Poor appetite
Achylous diarrhoea
Meteorism
Gastric juice examination
achlorhydria or achylia (pepsin & HCL absence)
Functional Dyspepsia
(Nonulcer dyspepsia)
Complaints of persistent dyspepsia with
FUNCTIONAL DYSPEPSIA
DISTINGUISHING FEATURES
Pain / discomfort - not episodic (tends to occur daily
FUNCTIONAL DYSPEPSIA
Diagnosis
Anxious patient
History of previous psychotropic medication
In young women - rule out pregnancy
In old age - exclude intraabdominal malignancy
Liver palpation & LFTs
Investigations
No diagnostic investigation
In old age - endoscopy or barium meal to resolve
doubt of malignancy
INTESTINAL DYSPEPSIA
Reasons
Exocrine pancreas dysfunction
Small intestine chronic inflammatory
diseases
Clinical picture
Abdomen inflation
Rumbling (borborygmus) in abdomen
Intensive flatus passage
Diarrhea with putrefactive or acid smell
Constipation (rare)
INTESTINAL DYSPEPSIA
(Inadequate digestion)
Fermentative dyspepsia
Disturbance in carbohydrates digestion caused by
INTESTINAL DYSPEPSIA
(Inadequate digestion)
Putrefactive dyspepsia
INTESTINAL DYSPEPSIA
(Inadequate digestion)
Fatty dyspepsia
by rapid passage of food from small into
large intestine - inadequate secretion of
lipase & disturbance in bile supply of
intestine
Feces - pale yellow colour, with neutral or
slightly alkaline action & contain significant
amount of fatty acid crystals & soaps
Fecal fat loss > 6 mg per 24 hours - abnormal
INTESTINAL DYSPEPSIA
Investigations
Coprological findings (steatorrhea, amylorrhea)
Stool examination by physician - as soon as possible after
DIARRHOEA
Stool weight increase > 300 g per day
Types:
Osmotic diarrhea
Secretory diarrhea
Inflammatory diarrhea
Abdominal motility diarrhea
Antibiotic-associated diarrhea
Osmotic diarrhea
Large quantities of non absorbed hypertonic
substances in gut lumen present
fluid enters bowel due to osmotic pressure:
Purgative intake
Generalized malabsorption
Specific malabsorption (disaccharidase
deficiency)
Osmotic diarrhea stops when patient stops
eating of malabsorptive substances
Secretory diarrhea
Active intestinal secretion of fluid &
electrolytes with decreased absorption:
Enterotoxin (cholera, E.coli)
Bile salts in colon following ileal
resection
Fatty acids in colon following ileal
resection
Food does not affect diarrhea - continues
during fasting
Inflammatory diarrhea
Damage to intestinal mucosal cells loss of fluid & blood:
Dysentery (Shigella)
Ulcerative colitis
Small bowel
diarrhea
Large bowel
diarrhea
Stool
volume
Large
Small
Dark
Small bowel
diarrhea
Large bowel
diarrhea
Stool smell
Very foul
Foul
Mucinous &
jelly like
Mucoid
Blood in
stool
Common (usually
fresh blood, if
from caecum
maroon coloured
Rare (if
present
altered)
Small bowel
diarrhea
Large bowel
diarrhea
WBCs in
stool
Rare
Common
Tenesmus
Absent
Present
Undigested
material
May be
seen
Invisible
Steatorrhea
May be
seen
Not seen
Frequency
Less
More
Management
Restoration of blood volume
Occult GI Bleeding
Is the lost of small amount of blood into tract
Etiology
All causes of upper and lower GI bleeding may
Diagnosis
1. Rectal examination, anoscopy and
sigmoidoscopy are performed to look for
evidence of anorectal disease, inflammatory
bowel disease or infectious colitis
- if source is identified, no further investigations
are needed immediately unless bleeding persist
or is recurrent
2. Exclude an upper tract source : pass
nasogastric tube in patients with significant
bleeding to look for evidence of upper GI source