Approach to the Patient with Gastrointestinal Disease 1.pptx

a case study

1. Approach to the Patient with Gastrointestinal Disease 

2. Classification Symptoms Signs Investigations

3. INTRODUCTION GI diseases develop as a result of abnormalities within or outside of the gut . R ange in severity from those that produce mild symptoms and no long-term morbidity to those with intractable symptoms or adverse outcomes. M ay be localized to one organ or exhibit diffuse involvement at many sites.

4. Classification of GI Diseases Impaired Digestion and Absorption Altered Secretion Altered Gut Transit Immune Dysregulation Impaired Gut Blood Flow

5. Neoplastic Degeneration Disorders Without Obvious Organic Abnormalities Genetic Influences

6. Impaired Digestion and Absorption M ost common intestinal maldigestion syndrome, lactase deficiency, produces gas and diarrhea after dairy products and has no adverse outcomes. C eliac disease, bacterial overgrowth, infectious enteritis, Crohn's ileitis, and radiation damage, which affect digestion and/or absorption more diffusely, produce anemia, dehydration, electrolyte disorders, or malnutrition.

7. Gastric hypersecretory conditions such as Zollinger -Ellison syndrome damage the intestinal mucosa, impair pancreatic enzyme activation, and accelerate transit . Biliary obstruction from stricture or neoplasm impairs fat digestion.

8. Impaired pancreatic enzyme release in chronic pancreatitis or pancreatic cancer can lead to malnutrition.

9. Altered Secretion Gastric acid hypersecretion occurs in Zollinger -Ellison syndrome, G cell hyperplasia, retained antrum syndrome. P atients with atrophic gastritis or pernicious anemia release little or no gastric acid.

10. Altered Gut Transit Impaired gut transit may be secondary to mechanical obstruction. Esophageal occlusion often results from acid-induced stricture or neoplasm. Gastric outlet obstruction develops from peptic ulcer disease or gastric cancer. Small-intestinal obstruction results from adhesions , Crohn's disease, radiation- or drug-induced strictures.

11. The most common cause of colonic obstruction is colon cancer. Achalasia is characterized by impaired esophageal body peristalsis and incomplete lower esophageal sphincter relaxation.

12. Gastroparesis is the symptomatic delay in gastric emptying of meals due to impaired gastric motility. Intestinal pseudoobstruction causes marked delays in small-bowel transit due to enteric nerve or intestinal smooth-muscle injury. Constipation also is produced by outlet abnormalities such as rectal prolapse, intussusception.

13. Disorders of rapid propulsion are less common. Rapid gastric emptying occurs in postvagotomy dumping syndrome, with gastric hypersecretion . Exaggerated intestinal or colonic motor patterns may be responsible for diarrhea in irritable bowel syndrome. Accelerated transit with hyperdefecation is noted in hyperthyroidism.

14. Immune Dysregulation M ucosal inflammation of celiac disease results from dietary ingestion of gluten-containing grains. Eosinophilic esophagitis and eosinophilic gastroenteritis are inflammatory disorders with prominent mucosal eosinophils . Ulcerative colitis and Crohn's disease are disorders of uncertain etiology that produce mucosal injury

15. Impaired Gut Blood Flow I ntestinal and colonic ischemia that are consequences of arterial embolus, arterial thrombosis, venous thrombosis, or hypoperfusion from dehydration, sepsis, hemorrhage, or reduced cardiac output.

16. Neoplastic Degeneration C olorectal cancer & gastric cancer is most common and usually presents after age 50 years. Esophageal cancer develops with chronic acid reflux Anal cancers arise after prior anal infection or inflammation.

17. Pancreatic and biliary cancers elicit severe pain, weight loss, and jaundice and have poor prognoses. Hepatocellular carcinoma usually arises in the setting of chronic viral hepatitis or cirrhosis secondary to other causes.

18. Disorders Without Obvious Organic Abnormalities N o abnormalities on biochemical or structural testing . I nclude irritable bowel syndrome, functional dyspepsia, functional chest pain, and functional heartburn. These disorders exhibit altered gut motor function.

19. Genetic Influences I nflammatory bowel disease & functional bowel disorders patients show a genetic predisposition.

20. Symptoms

21. Symptoms of Gastrointestinal Disease A bdominal pain, heartburn, nausea and vomiting, altered bowel habits, GI bleeding, jaundice, dysphagia, anorexia, weight loss, fatigue.

22. Abdominal Pain Visceral pain generally is midline in location and vague in character, while parietal pain is localized and precisely described.

23. Abdominal Pain causes Appendicitis Gallstone disease Pancreatitis Diverticulitis Ulcer disease Esophagitis

24. GI obstruction Inflammatory bowel disease Functional bowel disorder Vascular disease Gynecologic causes Renal stone

25. Nausea and Vomiting causes Medications GI obstruction Motor disorders Functional bowel disorder Enteric infection

26. Pregnancy Endocrine disease Motion sickness Central nervous system disease

27. Diarrhea Large bowel diarrhoea Small bowel diarrhoea Presence of blood and mucous floating, greasy, containing undigested food particles Tenesmus present absent Small-volume Large-volume stools Hypogastric cramps Mid-abdominal cramps

28. Diarrhea causes Infection Poorly absorbed sugars Inflammatory bowel disease Microscopic colitis Functional bowel disorder

29. Celiac disease Pancreatic insufficiency Hyperthyroidism Ischemia Endocrine tumor

30. GI Bleeding causes Ulcer disease Esophagitis Varices Vascular lesions Neoplasm Diverticula

31. Hemorrhoids Fissures Inflammatory bowel disease Infectious colitis

32. Jaundice Jaundice results from prehepatic , intrahepatic, or posthepatic disease.

33. Obstructive Jaundice causes Bile duct stones Cholangiocarcinoma Cholangitis Ampullary stenosis Ampullary carcinoma Pancreatitis Pancreatic tumor

34. Evaluation of the Patient with GI Disease H istory and examination. I nvestigation

35. H istory Symptoms of short duration commonly result from acute infection, toxin exposure, or abrupt inflammation or ischemia. Long-standing symptoms point to underlying chronic inflammatory or neoplastic conditions or functional bowel disorders.

36. Symptoms from mechanical obstruction, ischemia, inflammatory bowel disease, and functional bowel disorders are worsened by meals. Peptic ulcer symptoms may be relieved by eating or antacids.

37. Ulcer pain occurs at intermittent intervals lasting weeks to months. B iliary colic has a sudden onset and lasts up to several hours. Pain from acute pancreatitis is severe and persists for days to weeks.

38. Meals elicit diarrhea in some cases of inflammatory bowel disease and irritable bowel syndrome. Defecation relieves discomfort in inflammatory bowel disease and irritable bowel syndrome. Functional bowel disorders are exacerbated by stress.

39. Diarrhea from malabsorption usually improves with fasting. S ecretory diarrhea persists without oral intake.

40. Obstructive symptoms with prior abdominal surgery raise concern for adhesions, whereas loose stools after gastrectomy suggest dumping syndrome. Medications may produce pain, altered bowel habits, or GI bleeding. Lower GI bleeding likely results from neoplasms, diverticula, or vascular lesions in an older person and from anorectal abnormalities or inflammatory bowel disease in a younger individual.

41. A sexual history may raise concern for sexually transmitted diseases or immunodeficiency.

42. Physical Examination Fever suggests inflammation or neoplasm . Skin, eye, or joint findings may point to specific diagnoses . Neck exam with swallowing assessment evaluates dysphagia.

43. Pelvic examination tests for a gynecologic source of abdominal pain . Rectal exam may detect blood, indicating gut mucosal injury or neoplasm. Abdominal distention may result from obstruction, tumor, or ascites or vascular abnormalities with liver disease.

44. Palpation assesses for hepatosplenomegaly as well as neoplastic or inflammatory masses. P eritonitis have directed pain, often with involuntary guarding, rigidity, or rebound. Percussion assesses liver size and can detect shifting dullness from ascites.

45. Ecchymoses develop with severe pancreatitis . Bruits or friction rubs from vascular disease or hepatic tumors . Loss of bowel sounds signifies ileus. High-pitched , hyperactive sounds characterize intestinal obstruction.

46. INVESTIGATIONS Laboratory E xamination of luminal contents Radiographic F unctional tests Histopathologic U pper and lower endoscopy

47. Laboratory Iron-deficiency anemia suggests mucosal blood loss. Vitamin B12 deficiency results from small-intestinal, gastric, or pancreatic disease . Leukocytosis and increased sedimentation rates and C-reactive proteins are found in inflammatory conditions.

48. Severe vomiting or diarrhea elicits electrolyte disturbances, acid-base abnormalities, and elevated blood urea nitrogen. Pancreaticobiliary or liver disease is suggested by elevated pancreatic or liver chemistries . Thyroid chemistries, cortisol, and calcium levels are obtained to exclude endocrinologic causes of GI symptoms.

49. Serologic tests can screen for celiac disease, inflammatory bowel disease, rheumatologic diseases like lupus or scleroderma. Intraabdominal malignancies produce other tumor markers including the carcinoembryonic antigen CA 19-9 and –Alpha fetoprotein .

50. Ascitic fluid is analyzed for infection, malignancy, or findings of portal hypertension.

51. Luminal Contents Stool samples are cultured for bacterial pathogens, examined for leukocytes and parasites, or tested for Giardia antigen . Duodenal aspirates can be examined for parasites or cultured for bacterial overgrowth . Fecal fat is quantified in possible malabsorption .

52. Stool electrolytes can be measured in diarrheal conditions . Gastric acid is quantified to rule out Zollinger -Ellison syndrome. Pancreatic juice is analyzed for enzyme or bicarbonate content to exclude pancreatic exocrine insufficiency.

53. Endoscopy May provide the diagnosis of the causes of bleeding, pain, nausea and vomiting, weight loss, altered bowel function , and fever. Upper endoscopy evaluates the esophagus, stomach, and duodenum. C olonoscopy assesses the colon and distal ileum . I ts ability to directly visualize as well as biopsy the abnormality.

54. Upper endoscopy is performed in patients with suspected ulcer disease, esophagitis, neoplasm, malabsorption , and Barrett's metaplasia.

55. Colonoscopy is the procedure of choice for colon cancer screening and diagnosis of colitis secondary to infection, ischemia, radiation, and inflammatory bowel disease . Sigmoidoscopy examines the colon up to the splenic flexure and is used to exclude distal colonic inflammation or obstruction in young patients.

56. Capsule endoscopy also can visualize small-intestinal Crohn's disease in individuals with negative barium radiography . Endoscopic retrograde cholangiopancreaticography (ERCP) provides diagnoses of pancreatic and biliary disease.

57. Radiography/Nuclear Medicine Oral or rectal contrast agents like barium provide mucosal definition of GIT & also assesses gut transit and pelvic floor dysfunction . Barium swallow is the initial procedure for evaluation of dysphagia to exclude subtle rings or strictures and assess for achalasia.

58. Contrast enemas are performed when colonoscopy is unsuccessful or contraindicated.

59. Ultrasound and computed tomography (CT) evaluate regions not accessible by endoscopy or contrast studies, including the liver, pancreas, gallbladder, kidneys, and retroperitoneum . Angiography excludes mesenteric ischema. Positron emission tomography can facilitate distinguishing malignant from benign disease in several organ systems.

60. Radiolabeled leukocyte scans can search for intraabdominal abscesses not visualized on CT .

61. Histopathology Gut mucosal biopsies obtained for inflammatory, infectious, and neoplastic disease. Deep rectal biopsies assist with diagnosis of Hirschsprung's disease or amyloid. Liver biopsy is indicated in cases with abnormal liver chemistries, unexplained jaundice, following liver transplant to exclude rejection.

62. Biopsies obtained during CT or ultrasound can evaluate for other intraabdominal conditions not accessible by endoscopy.

63. Functional Testing G astric acid and pancreatic function testing. Esophageal manometry is useful for suspected achalasia. Small-intestinal manometry tests for pseudoobstruction .

64. Anorectal manometry is employed for unexplained incontinence or constipation. Biliary manometry tests for sphincter of Oddi dysfunction with unexplained biliary pain . Measurement of breath hydrogen while fasting and after oral mono- or oligosaccharide challenge to screen for carbohydrate intolerance.