CLINICAL FEATURES and INVESTIGATIONS in GASTROENTEROLOGY

1. CLINICAL FEATURES and INVESTIGATIONS in GASTROENTEROLOGY

2. Sensation of “sticking” or obstruction of the passage of food through the mouth, pharinx or the esophagus. • Dysphagia (D) should be distinguished from other symptoms related to swallowing. • Aphagia – complete esophageal obstruction – medical emergency • Difficulty in initiating a swallow occurs in disorders of the voluntary phase of swallowing • Odynophagia(O) painful swallowing • Frequently O + D occur together

3. Globus hystericus – sensation of a lump lodged in the throat. • Phagophobia – fear of swallowing • Refusal to swallow: hysteria, rabies, tetanus, pharyngeal paralysis • Feeling of fulness in the epigastrium after a meal or swallowing air ≠ dysphagia

4. Approach to the patient with D • History – diagnosis in 80% of patients • The type of food – useful information • Difficulty only with solids – mechanical D; the lumen is not severely narrowed (drinking liquids through the narrowed area force the impacted bolus) • Advanced obstruction – D with liquids/solids • Motor D (achalasia + esophageal spasm) total D from the onset • Scleroderma – D to solids unrelated to posture/liquids in the recumbent, but not in the upright posture

5. Peptic stricture developes – D became more persistent • The duration and course of D – helpful in diagnosis • Transient D of short duration – inflammatory process • Progressive D of a few weeks to a few month’s duration – carcinoma of the esophagus • Episodic D to solids of several years duration – benign disease of the esophageal ring • Associated symptoms provide important diagnostic clues • Nasal regurgitation • tracheobronchial aspiration + swallowing hallmarks of pharingeal paralysis/tracheoesophageal fistula

6. ACHALASIA ZENKER’S DIVERTICULUM GERD laryngitis secondary GER • Tracheobronchial aspiration unrelated to swallowing • Severe weight loss – carcinoma • Hoarseness – precedes/following D → • larynx primary lesion, • recurrent laryngeal nerve caused by extension of esophageal carcinoma

7. Prolonged nasogastric intubation • Ingestion of caustic agents • Previous radiation therapy causes of esophageal strictures • Hiccups suggest lesion in the distal portion of esophagus • Unilateral wheezing + D→ mediastinal mass → esophagus/large bronchus • Chest pain + D → esophageal spasm (motor disorders) • Prolonged history of heartburn and GER preceding D → PEPTIC STRICTURE • Odynophagia: candidal, herpes esophagitis suspected • AIDS → esophagitis

8. PHYSICAL EXAMINATION • Important in motor D due to skeletal muscle, neurologic, oropharyngeal diseases • Neck → thyromegaly/spinal abnormality • Careful inspection of the mouth + pharynx → lesion → pain/obstruction • Changes in the skin, extremities • Scleroderma • Collagen vascular diseases • Mucocutaneous diseases(pemphigoid,epidermolysis bullosa) • Pulmonary complications – acute aspiration pneumonia • Metastatic diseases to limph nodes and liver

9. DIAGNOSTIC PROCEDURES • BARIUM SWALLOW + CINERADIOGRAPHY • ESOPHAGOGASTROSCOPY+BIOPSY+EXFOLIATIVE CYTOLOGY • ESOPHAGEAL MOTILITY • PH-METRY • ESOPHAGEAL IMPEDANCE • ECHOENDOSCOPY • COMPUTER TOMOGRAPHY • MAGNETIC RESONANCE

10. ANOREXIA (A) • In diseases of GIT and liver • It may precede the jaundice in Acute Hepatitis • Prominent symptom in gastric carcinoma • A ≠ SITOPHOBIA (fear of eating because of subsequent abdominal discomfort) • A may be a prominent feature of extraintestinal diseases • Chronic pain from any source →loss of appetite • In cancer, A results from anxiety, pain, decreased sense of taste + smell, effects of the tumor on the GIT (tumor necrosis factor)

11. Medications:Antihypertensive Diuretics Digitalis Narcotic analgesics • Psychogenic disturbances – A nervosa • Congestive heart failure/Respiratory failure • Endocrinopathies/hyperparathyroidism, Addison’s disease Mechanism of hunger + apetite Food intake is reglated by 2 hypotalamic centers: • Lateral “feeding center” • Ventromedial “satiety center” • CCK (brain gut peptide) – satiety effect

12. NAUSEA AND VOMITING • common manifestations of many organic/functional disorders • ACUTE ABDOMINAL EMERGENCIES leads to “SURGICAL ABDOMEN” • acute appendicitis • acute cholecystitis • intestinal obstruction • acute peritonitis • DISORDERS OF THE ALIMENTARY TRACT • peptic ulcer • GI motility disorders • Postvagotomy • Diabetus • Idiopathic gastroparesis • Liver, pancreas, biliary tract disorders

13. VIRAL, BACTERIAL, PARASITIC INFECTIONS OF THE IT • ACUTE SYSTEMIC INFECTIONS – young children→ FEVER • CENTRAL NERVOUS SYSTEM DISORDERS • neoplasms • encephalitis • Meniere’s disease • migraine headaches • acute meningitis • ACUTE MYOCARDIAL INFARCTION • CONGESTIVE HEART FAILURE • CANCER – patients terminally ill • METABOLIC + ENDOCRINOLOGIC DISORDERS • HYPEREMESIS GRAVIDARUM

14. SIDE EFFECTS OF DRUGS: • digitalis • morphine • chemotherapeutic agents • ingestion of a toxic (food poisoning) • PHYCHOGENIC VOMITING:anorexia nervosa, bulimia Relationship of vomiting (V) to eating → diagnostic • V that occurs in the morning: pregnancy, uremia • Alcoholic gastritis – early-morning retching, emesis • V shortly after eating → peptic ulcer + pylorospasm • V 4-6 h after eating → pyloric obstruction, esophageal disorders (achalasia, Zenker’s diverticulum) • Relief of abdominal pain with vomiting→ peptic ulcer • rarely satiety→ gastroparesis

15. INDIGESTION • represents a challenging + difficult diagnostic problem because of its nonspecific nature • Abdominal pain – evaluated with Rx, imaging studies of the esophagus, stomach, small intestine, colon, pancreas,biliary tract. • ESOPHAGOGASTROSCOPY • ERCP • COLONOSCOPY • Empiric trials of antiacids, H2-Rblocking drugs or sucralfat are used in patients < 40 years with epigastric pain • SDE- persistent symptoms despite therapy/recur soon after discontinued therapy

16. H pylori patients – oral AB 7 days after SDE + biopsy • Excessive gas, bloating, distension, flatulence → questionary: dietary preferences relation of symptoms to specific foods • Elimination of milk, legumes from the diet → confirmatory NONULCER DYSPEPSIA-disturbances of GI motility Esophagus-Substernum,epigastrium-Peptic esophagitis,stricture,esophageal spasm,carcinoma Stomach-Epigastrium-Gastritis,gastric ulcer,carcinoma Duodenum1+2-Epigastrium-Duodenal ulcer Small intestine-Periombilical-Enteritis,lymphoma,obstruction Gallbladder,pancreas,liver-Epg.,right,left upper qt.,back-Cholelithiasis,Pancreatitis,Hepatitis,Cirrhosis,carcinoma.

17. Colon-below umbilicus-UC,carcinoma,obstruction • Non-ulcer dyspepsia-20-30% of population Helicobacter pylori + chronic gastritis • Heartburn (pyrosis): • reflux of acid/bile into the esophagus • after a large meal • in supine • Fluid in the mouth: salty (“water brash”) sour (gastric contents) bitter green/yellow (bile) • After citrus fruit juices, drugs (alcohol, aspirin)

18. Food intolerance • Carcinoma -discomfort for solids • Citrus ↓ pH → peptic ulcer, esophagitis • Deficiency of a specific enzyme (lactase-milk) • abdominal cramps • distention • diarrhea • flatulence • Allergic reactions – urticaria, angioedema, asthma • Toxic effects – gluten in celiac sprue • History of fatty food intolerance or distress after spicy foods is commonly in patients with indigestion

19. ERUCTATION (BELCHING) • Chronic anxiety • Rapid eating • Drinking carbonated beverages • Gum chewing • Postnasal drip • Poorly fitting dentures • 20-60% of intestinal gas is swallowed air • gastric bubble syndrome • splenic flexure syndrome-fullness in left upper quadrant with radiation to the left side of the chest • ↑ tympany + air in the splenic flexure of the colon on a plain abdominal radiograph

20. GASEOUSNESS, BLOATING, FLATULENCE • Motility disturbances • Fermentative action of intestinal bacteria or carbohydrates and proteins within the lumen CO2 small intestine → HCl, ingested fatty acids are neutralized by bicarbonate 1/3 of adults produce methane in the colon unrelated to food ingestion • Ex. Beans contain oligosaccharides that can’t be split by intestinal mucosal enzymes, but are metabolised by colonic bacteria • Increased intraluminal gas may result from abnormal bacterial colonization of the small intestine or infection with Giardia lamblia

21. WEIGHT GAIN • CAUSES OF OBESITY • Excess caloric intake • Cushing’s syndrome • Hypothyroidism • Hypogonadism • Insulin-secreting tumors • Cranyopharyngioma (disense of hypotalamus) WEIGHT LOSS • more often a diagnostic problem than weight gain, a sign of serious organic illness.

22. DIABETES MELLITUS • ↑ insulin-dependent form (insulin deficiency + ↑ glucagon) cause accelerated proteolysis and lipolysis → net energy state is catabolic • Weight loss is associated with increased food intake ENDOCRINE DISEASE • THYROTOXICOSIS • PHEOCHROMOCYTOMA → catecholamine release • PANHYPOPITUITARISM • ADRENAL INSUFFICIENCY → cortisol deficiency

23. GASTROINTESTINAL DISEASE • Inflammatory bowel disease • Parasites • Esophageal strictures • Chronic peptic ulcer • Pernicious anemia • Cirrhosis liver INFECTION • Tuberculosis • Fungal disease • Amoebic abcess • Subacute bacterial endocarditis • HIV • Cause: inflammatory cytokines

24. MALIGNANCY • GIT • Pancreas • Liver • Lymphoma • Leukemia PSYCHIATRIC DISEASE • Schizophrenia • Depression RENAL DISEASE

25. Upper GI Bleeding Peptic ulcer Gastritis Varices Mallory-Weiss syndrome Gastric carcinoma Lymphoma Polyps Dyscrasias, vasculitis Lower GI Bleeding Anal + rectal lesions Colonic lesions, carcinoma, angiodysplasia, UC, ischemic colitis Diverticula Meckel’s congenital distal ileum – 2% GASTROINTESTINAL BLEEDING- etiology -

26. HISTORY • Ulcer disease • Recent heavy use of alcohol/AIND → erosive gastritis, esophageal varices • Aspirin → gastroduodenitis peptic ulceration bleeding • Acute onset of bloody diarrhea → IBD

27. PHYSICAL EXAM • DERMATOLOGIC • telangiectasia Osler-Weber-Rendu • perioral pigmentation of Peutz-Jeghers • diffuse pigmentation hemochromatosis • spider angiomata • gynecomastia • testicular atrophy • jaundice • ascites • hepatosplenomegaly – HTP → varices • abdominal mass → malignancy • RECTAL EXAMINATION → local pathology color of the stool

28. LAB STUDIES • Hb, Ht, WC, IP • Radiography of the abdomen → perforation, ischemia is suspected • Repeated evaluation of the lab data-clinical course of the bleeding. • CONSTIPATION and DIARRHEA • -functional and organic disorders • IRRITABLE BOWEL,colonictumors,IBD,mucosal disorders ,sprue,pancreaticinsufficiency,postgastrectomy,endocrinediseases,habitual.

29. DIAGNOSTIC • ENDOSCOPY:diagnostic treatment: coagulation Nd-YAG laser, elecrocautery, sclerotherapy of varices • ANGIOGRAPHY:localise the site of bleeding intraarterial infusions of vasoconstrictor agents/vasopressin • COLONOSCOPY: GI bleeds, polypectomy/electrocoagulation • Barium enema – limited role • Arteriography– active blood loss > 0,5 ml/min • Bleeding scans