2-Clinical & presenting problem in GIT disease.pdf

Clinical Feature and presenting problem in GIT disease

1. 1BY:HUSSEIN JASSIM
GASTROENTEROLOGY
LECTURE II
Lecture 2
1-Clinical examination of the gastrointestinal tract
2-Presenting problems in gastrointestinal disease

2. 2
PART 1
CLINICAL EXAMINATION OF THE GASTROINTESTINAL TRACT

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PART 2
PRESENTING PROBLEMS IN GASTROINTESTINAL DISEASE

7. Dysphagia
•Dysphagia is defined as difficulty in swallowing.
•It may coexist with heartburn or vomiting but
should be distinguished from both globus
sensation (in which anxious people feel a lump in
the throat without organic cause) and
odynophagia(pain during swallowing, usually from
gastro-oesophagealreflux or candidiasis).
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8. Investigation of dysphagia
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9. Dyspepsia
•Dyspepsia describes symptoms such as discomfort,
bloating and nausea, which are thought to originate
from the upper gastrointestinal tract.
•Heartburn and other ‘reflux’ symptoms are separate
entities and are considered elsewhere.
•Dyspepsia affects up to 80% of the population at some
time in life and most patients have no serious
underlying disease.
•People who present with new dyspepsia at an age of
more than 55 years and younger patients
unresponsive to empirical treatment require
investigation to exclude serious disease.
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12. Heartburn and regurgitation
•Heartburn describes retrosternal, burning
discomfort, often rising up into the chest and
sometimes accompanied by regurgitation of acidic or
bitter fluid into the throat.
•These symptoms often occur after meals, on lying
down or with bending, straining or heavy lifting.
•They are classical symptoms of gastro-oesophageal
reflux but up to 50% of patients present with other
symptoms, such as chest pain, belching, halitosis,
chronic cough or sore throats.
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13. Vomiting
•Vomiting is a complex reflex involving both
autonomic and somatic neural pathways.
•Synchronous contraction of the diaphragm,
intercostal muscles and abdominal muscles raises
intra-abdominal pressure and, combined with
relaxation of the lower oesophagealsphincter,
results in forcible ejection of gastric contents.
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15. Constipation
•Constipation is defined as infrequent passage of hard
stools.
•Patients may also complain of straining, a sensation of
incomplete evacuation and either perianal or
abdominal discomfort.
•Constipation can be acute, typically lasting less than 1
week, or chronic, lasting greater than 4 weeks.
•Chronic constipation is normally due to a primary
cause, such as dietary intake (e.g. insufficient fibre),
lifestyle factors (e.g. sedentary lifestyle) or disorders of
rectal evacuation.
•Secondary causes of chronic constipation are
numerous, including drugs such as opiates.
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17. Diarrhoea
•Diarrhoeais defined as the passage of three or
more loose or liquid stools per day.
•Stool weight was previously used to define
diarrhoea(> 200g stool per day), but is no longer
recommended as normal stool volumes can exceed
this value.
•The most severe symptom in many patients is
urgency of defecation, while faecalincontinence
can occur in acute and chronic diarrhoealillnesses.
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18. •Acute diarrhoea
•This is extremely common and is usually caused by faecal–oral transmission of
bacteria or their toxins, viruses or parasites.
•Infective diarrhoeais usually short-lived and patients who present with a history
of diarrhoealasting more than 10 days rarely have an infective cause.
•A variety of drugs, including antibiotics, cytotoxic drugs, PPIs and NSAIDs, may be
responsible.
•Chronic or relapsing diarrhoea
•Chronic diarrhoeacan be categorisedas being caused by disease of
the colon or small bowel, or due to malabsorption.
•Clinical presentation, examination of the stool, routine blood tests and imaging
reveal a diagnosis in many cases.
•Young patients (< 40 years) with typical symptoms of a functional bowel disorder,
with negative initial investigations, may have a diagnosis of irritable bowel
syndrome.
•The stool often contains mucus but never blood, and 24-hour stool volume is less
than 200 g.
•Chronic diarrhoeacan be categorisedas being caused by disease of the colon or
small bowel, or to malabsorption
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20. Mechanisms of Diarrhea
❑Osmotic diarrhea: large amount of non absorbed
hypertonic substances in lumen:
1.Ingestion of non absorbable sub. ,e.gpurgative
Mg sulphate
2.Generalized Malabsorption
3.Specific Malabsorptiondisaccharides deficiency
•Volume of stool is reduced by absorption of fluid
by ileum &colon &by fasting
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21. Mechanisms of Diarrhea
❑Secretary Diarrhea : active intestinal secretion of fluid &
electrolyte & dec.absorption causes:
1.Enterotoxin e.g. cholera
2.Hormones VIP
3.Bile salts, fatty acids after ilealresection
4.Some laxative
•Stool volume very high continues during fasting
❑Inflammatory diarrhea:
•Mucosal destruction ,loss of fluid, blood &defect In
absorption of fluid &electrolyte, common causes infection
e.g. dysentery due to shegilla& inflammatory bowel disease
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22. Malabsorption
•Diarrhoeaand weight loss in patients with a normal diet are
likely to be caused by malabsorption.
•The symptoms are diverse in nature and variable in severity.
•A few patients have apparently normal bowel habit, but
diarrhoeausually occurs and may be watery and
voluminous.
•Bulky, pale and offensive stools that float in the toilet
(steatorrhoea) signify fat malabsorption.
•Abdominal distension, borborygmi, cramps, weight loss and
undigested food in the stool may be present.
•Some patients complain only of malaise and lethargy.
•In others, symptoms related to deficiencies of specific
vitamins, trace elements and minerals may occur.
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25. Weight loss
•Weight loss may be physiological, due to dieting, exercise,
starvation, or the decreased nutritional intake that
accompanies old age.
•Weight loss of more than 5% of usual body weight over 6–12
months is clinically important and can indicate the presence
of an underlying disease.
•Hospital and general practice weight records may be
valuable in confirming that weight loss has occurred, as may
reweighing patients at intervals; sometimes weight is
regained or stabilisesin those with no obvious cause.
•Pathological weight loss can be due to psychiatric illness,
systemic disease, gastrointestinal causes or advanced
disease of many organ systems.
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27. Abdominal pain
❑There are four types of abdominal pain:
•Visceral: Gut organs are insensitive to stimuli such as burning and cutting but are
sensitive to distension, contraction, twisting and stretching.
•Pain from unpaired structures is usually, but not always,feltin the midline.
•Parietal: The parietal peritoneum is innervated by somatic nerves and its
involvement by inflammation, infection or neoplasia causes sharp, well-
localisedand lateralisedpain.
•Referred pain: Gallbladder pain, for example, may be referred to the back or
shoulder tip.
•Psychogenic: Cultural, emotional and psychosocial factors influence everyone’s
experience of pain.
•In some patients, no organic cause can be found despite investigation, and
psychogenic causes (depression or somatisationdisorder) may be responsible.
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28. Chronic or recurrent abdominal pain
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