Gastrointestinal diseases

Categories of symptoms
1. Symptoms of organic disease
- achalasia, duodenal ulcer, celiac disease,
ulcerative colitis, regional enteritis
2. Psychophysiologic disorders
- increased peristalsis after stress
3. Symptoms of psychiatric disease
- constipation, clears after antidepressant
medication
- globus hystericus, clears after tranquilizers
 Common functional disorders of the
GI tract
I. Disorders of swallowing
A. Globus hystericus
B. Esophageal spasm (peristalsis)
C. Heartburn (incompetence of inf sphyncter)
II. Disorders of stomach and duodenum
A. Pyloric dysfunction (dyspepsia, nausea, vomiting)
B. GI bleeding
III. Disorders of the colon (irritable colon syndrome)
A. Pain and constipation
B. Intermittent diarrhea
IV. Disorders of the anus
A. Fecal incontinence
B. Proctalgia fugax
C. Pruritus ani
 Diagnosis
 History taking
! Stressful life situations, effect of
stress cessation
! Social history
 Physical examination
 Lab studies
 Example: Life chart of patient
Age Life situation
13-20 Home, father died
20-23 Near home, nursing training
23-27 Away from home, private
28 Mother ill, terminal illness
Patient cared for her at home
29-30 Returned to private duty
nursing
31-36 Worked as nurse anesthetist
Bowel function
Irregular constipation
Steadily constipated
Regular, no laxatives
Severely constipated
Regular, no laxatives
Severely constipated
 Globus hystericus
 Sensation of “lump” in the throat
 Related to stress (choked up)
 Careful history! for diff dg:
- symptomatic esophageal spasm
- gastroesophageal reflux
- myastenia, polymyositis
- mediastinal compression
 Symptoms do not worsen during swallowing
 Relieved by eating, drinking
 Esophageal manometry
Tr: antidepressives
 Esophageal spasm
 Neurogenic disorder of esophageal
motility with phasic nonpropulsive
contractions
 Substernal chest pain, dysphagia for
liquids and solids
 X-ray – poor progression of bolus
 Esomanometry – lower esoph sphincter
pressure impaired
Tr: Ca-ch blockers, dilation
 Heartburn
 Caused by gastroesophageal reflux, with
incompetence of lower esophageal sphincter
 Dg: -history
- X-ray Trendelenburg
- esophagoscopy
- esomanometry
- biopsy
Tr: - elevate head of bed
- avoid stimulants of secretion
- avoid specific foods, drugs, smoking
- antacid 1h after meals
- increase sphincter pressure (metoclopramide)
 Dyspepsia
 Indigestion, fullnes or pain localized in
upper abdomen of chest
 Abdominal distension, borborygmus
 Association of symptoms: duodenitis,
pyloric dysfunction, motility disturbances,
cholelitiasis
 !psychologic causes – somatization
 ! Gastric infection with Helicobacter pylori
Tr: reassurance, continued observation
 GI bleeding
Common causes upper GI tract:
- Duodenal ulcer
- Gastric erosions
- Varices
- Gastric ulcer
- Mallory-Weiss tear
- Erosive esophagitis
- Angioma
 GI bleeding
Common causes lower GI tract:
- Diverticular disease
- Colonic carcinoma
- Colonic polyps
- Inflammatory bowel disease
- Colitis (radiation, ischemic)
- Internal hemorrhoids
- Anal fissures
Small bowel lesions:
- Meckel’s diverticulum
- Neoplasms
 GI bleeding
 Vomiting of blood=hematemesis
 Passage of black stool=melena
 Passage of blood=hematochezia
- Symptoms depend on source and rate of
bleeding:
- shock, massive
- anemia, occult
- ortostatic changes in BP and HR
 GI bleeding
 Dg
- history – do not forget NSAIDS
- phys exam: assess vital signs
exclude nose/throat
exclude trauma
exclude liver disease
digital rectal exam
 Nasogastric aspiration
 Panendoscopy
 Emergency – send to ICU
 Peptic ulcer
 Dg
- chronic recurrent course
- symptoms vary with age and location
(asymptomatic →1/2 characteristic steady
burning pain in epigastrium, relieved by
antacids/milk, period free of pain after meals)
- endoscopy-cytologic search
- X-ray studies with barium
- gastric secretory studies (suspected Zollinger-
Ellison syndrom)
 Peptic ulcer
 Treatment

- nonabsorbable antacids Al (OH)3, Mg(OH)2 1h after meals

- H2 receptor antagonists ( cimetidine 800, ranitidine 300,
famotidine 40, nizatidine 300 at bedtime) 6 wk, repeat
endoscopy
- sucralfate – protective coating 1g tid
- inhibitors of proton pump – omeprazole 20-80 mg /day,
single dose or bid 2-4 wk DU, 6 wk GU
- Pg E2, misoprostol prevention of ulcers caused by NSAIDS

! H2 antagonists of no use in acute pancreatitis

! Persistent abdominal symptoms after 2 wk of therapy require
diagnostic reevaluation
 Peptic ulcer
 H. pylori, a spiral-shaped bacterium present in more than 90% of
patients with intestinal (duodenal) ulcers and in more than 80% of
those with stomach (gastric) ulcers

 4 drug regimens
Bi+Metro+Amoxi+H2Bl
Bi+Metro+Clarithro+PPI

 3 Drug regimens
Clarithro+Metro+PPI
Amoxi+Clarithro+PPI
Tetra+Metro+Sucralfate

 All taken for 2 weeks

 Peptic ulcer
 Adjunctive treatment
- diet – avoid pepper, spicy foods,
fatty foods, coffee, alcohol
- quit smoking
- consider surgery in recurrences
- hospitalization if complications
occur
 Peptic ulcer
Complications
- penetration
- perforation
- hemorrhage
- obstruction
 Acute pancreatitis
 Dg
- Severe abdominal pain that radiates to the
back
- Patient acutely ill, sweating
- HR 100-140, BP low, shock
- Sensorium blunted, semi-coma
- Upper abdominal distension
- Peritoneal irritation
- Hypoactive bowel sounds
Acute pancreatitis
 Diff dg
- Perforated G/D ulcer
- Mesenteric infarction
- Intestinal obstruction with strangulation
- Dissecting AO aneurism
- Biliary colic
- Appendicitis
- Diverticulitis
- Ectopic pregnancy
 Acute pancreatitis
 Lab
- Serum amylase and lipase elevated
- Increased WBC 12,000-20,000
- Increased Ht 50% due to fluid losses
- Hyperglycemia
 Acute pancreatitis
 Investigations
- Supine and plain films of the
abdomen
- Chest Xray
- US
- CT
 Acute pancreatitis
 Treatment
- Severe acute pancreatitis → send to ICU
- Mild edematous pancreatitis
- maintain pt in fasting state until cessation
of abdominal tendetness, normalization of
amylase and return of hunger
- infuse sufficient iv fluids to prevent
hypovolemia and hypotension
- insert nasogastric tube to remove gastric
fluid and air if ileus is present
 Diarrhea
 Dg

History
– place, time, circumstances of onset, duration, severity
- presence of overt or occult blood in stool
- evidence of steatorrhea
- changes of weight
- use of dietetic products/appetite
- Presence of rectal tenesmus

! Diarrhea is a symptom. Find underlying disorder

 Diarrhea
 Causes
- Osmotic diarrhea (lactase deficiency,
sucrose, mannitol, chewing-gum)
- Secretory diarrhea (enteropathic viruses,
bile acids, VIPomas)
- Malabsorbtion (nontropical sprue)
- Exudative diarrhea (mucosal diseases-
ulcerative colitis, regional enteritis, TB)
- Altered intestinal transit (gastric resection,
surgical by-pass, laxatives)
Diarrhea
 Treatmnet
- Increase intestinal tone-codeine P, opium
tincture
- Decrease peristalsis – belladona tincture,
atropine
- Replace fluids and electrolytes – monitor
in hospital
- Oral glucose-electrolyte solution
- Dietary changes
 Constipation
 Dg
- acute/chronic
- Ac: consider mechanical bowel
obstruction, adynamic ileus, careful drug
history (antacids, anticholinergics, Bi, Fe)
- Cr: irritable bowel, colonic inertia,
megacolon, systemic disorders,
neurologic disorders
 Constipation
 Tr
- Diet –high fiber
- Bulking agents methylcellulose
- Laxatives
- Osmotic agents –lactulose, sorbitol
- Secretory stimulants – senna,
cascara
 Anorectal dysfunction
Procedures:
- Perform digital rectal exam/anuscopy
- Visually inspect stool
- Perform guaiac test on stool
Dg
- External/internal hemorrhoids
- Anal fissure
- Anal fistula
- Perirectal abscess
- Peutz-Jeghers syndrome
- Rectal prolapse
- GI bleeding
- Parasites
 Digital anorectal exam
 Place pt in right/left lateral decubitus
 Visually inspect and palpate anal and
perineal structures
 Palpate mucosa and submucosal
structures with index finger
 Note and describe lesions
 Visually inspect stool
 Mucus- inflammation
 Bright red blood – GI bleeding
 Black, sticky, guaiac + = melena
 Greasy = steatorrhea
 Parasites
 Guaiac test
 Place a sample of stool on guaiac
card, place a drop of reagent and
observe change of color
 Blue = presence of hemoglobin in
stool = GI bleeding