CLINICAL FEATURES CLINICAL FEATURES and and

INVESTIGATIONS in INVESTIGATIONS in GASTROENTEROLOGGASTROENTEROLOG

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Sensation of Sensation of “sticking”“sticking” or obstruction of or obstruction of the passage of food through the mouth, the passage of food through the mouth, pharinx or the esophagus.pharinx or the esophagus.

Dysphagia (D) should be distinguished Dysphagia (D) should be distinguished from other symptoms related to from other symptoms related to swallowing.swallowing.

AphagiaAphagia – complete esophageal – complete esophageal obstruction – medical emergencyobstruction – medical emergency

Difficulty in initiatingDifficulty in initiating a swallow a swallow occurs in disorders of the voluntary occurs in disorders of the voluntary phase of swallowingphase of swallowing

OdynophagiaOdynophagia (O) painful swallowing(O) painful swallowing Frequently O + D occur togetherFrequently O + D occur together

Globus hystericusGlobus hystericus – sensation of a – sensation of a lump lodged in the throat.lump lodged in the throat.

PhagophobiaPhagophobia – fear of swallowing – fear of swallowing Refusal to swallow: hysteria, rabies, Refusal to swallow: hysteria, rabies,

tetanus, pharyngeal paralysistetanus, pharyngeal paralysis Feeling of fulness in the Feeling of fulness in the

epigastrium after a meal or epigastrium after a meal or swallowing air swallowing air ≠≠ dysphagia dysphagia

Approach to the patient Approach to the patient with Dwith D

HistoryHistory – diagnosis in 80% of patients – diagnosis in 80% of patients The type of foodThe type of food – useful information – useful information Difficulty only with solids – mechanical D; Difficulty only with solids – mechanical D;

the lumen is not severely narrowed the lumen is not severely narrowed (drinking liquids through the narrowed area (drinking liquids through the narrowed area force the impacted bolus)force the impacted bolus)

Advanced obstructionAdvanced obstruction – D with liquids/solids – D with liquids/solids Motor DMotor D ( (achalasia + esophageal spasmachalasia + esophageal spasm) )

total D from the onsettotal D from the onset SclerodermaScleroderma – D to solids unrelated to – D to solids unrelated to

posture/liquids in the recumbent, but not in posture/liquids in the recumbent, but not in the upright posture the upright posture

Peptic stricturePeptic stricture developes – D became more developes – D became more persistentpersistent

The duration and course of D – helpful in The duration and course of D – helpful in diagnosisdiagnosis

Transient DTransient D of short duration – inflammatory of short duration – inflammatory processprocess

Progressive DProgressive D of a few weeks to a few month’s of a few weeks to a few month’s duration – carcinoma of the esophagusduration – carcinoma of the esophagus

Episodic DEpisodic D to solids of several years duration – to solids of several years duration – benign disease of the esophageal ringbenign disease of the esophageal ring

Associated symptomsAssociated symptoms provide important provide important diagnostic cluesdiagnostic clues

Nasal regurgitationNasal regurgitation tracheobronchial aspiration + swallowingtracheobronchial aspiration + swallowing

hallmarks of pharingeal paralysis/tracheoesophageal hallmarks of pharingeal paralysis/tracheoesophageal fistulafistula

Tracheobronchial aspiration unrelated Tracheobronchial aspiration unrelated to swallowingto swallowing

Severe weight lossSevere weight loss – carcinoma – carcinoma HoarsenessHoarseness – precedes/following D → – precedes/following D →

larynx primary lesion,larynx primary lesion, recurrent laryngeal nerverecurrent laryngeal nerve caused by caused by

extension of esophageal carcinomaextension of esophageal carcinoma

ACHALASIAZENKER’S DIVERTICULUM

GERD

laryngitis secondary GERlaryngitis secondary GER

HiccupsHiccups suggest lesion in the distal suggest lesion in the distal portion of esophagusportion of esophagus

Unilateral wheezing + DUnilateral wheezing + D → mediastinal mass → esophagus/large bronchus→ esophagus/large bronchus

Chest pain + DChest pain + D → esophageal spasm → esophageal spasm (motor disorders)(motor disorders)

Prolonged history of Prolonged history of heartburnheartburn and and GERGER preceding D → PEPTIC STRICTUREpreceding D → PEPTIC STRICTURE

OdynophagiaOdynophagia: candidal, herpes : candidal, herpes esophagitis suspectedesophagitis suspected

AIDS AIDS → esophagitis→ esophagitis

•Prolonged nasogastric intubation•Ingestion of caustic agents•Previous radiation therapy

causes of esophagealstrictures

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION Important in motor D due to skeletal muscle, Important in motor D due to skeletal muscle,

neurologic, oropharyngeal diseasesneurologic, oropharyngeal diseases Neck → thyromegaly/spinal abnormalityNeck → thyromegaly/spinal abnormality Careful inspection of the mouth + pharynx → Careful inspection of the mouth + pharynx →

lesion → pain/obstructionlesion → pain/obstruction Changes in the skin, extremitiesChanges in the skin, extremities

SclerodermaScleroderma Collagen vascular diseasesCollagen vascular diseases Mucocutaneous Mucocutaneous

diseases(pemphigoid,epidermolysis bullosa)diseases(pemphigoid,epidermolysis bullosa) Pulmonary complications – acute aspiration Pulmonary complications – acute aspiration

pneumoniapneumonia Metastatic diseases to limph nodes and liver Metastatic diseases to limph nodes and liver

DIAGNOSTIC PROCEDURESDIAGNOSTIC PROCEDURES

1.1. BARIUM SWALLOW + CINERADIOGRAPHYBARIUM SWALLOW + CINERADIOGRAPHY2.2. ESOPHAGOGASTROSCOPY+BIOPSY+EXFOLIATIVE CYTOLOGYESOPHAGOGASTROSCOPY+BIOPSY+EXFOLIATIVE CYTOLOGY3.3. ESOPHAGEAL MOTILITYESOPHAGEAL MOTILITY4.4. PH-METRYPH-METRY5.5. ESOPHAGEAL IMPEDANCEESOPHAGEAL IMPEDANCE6.6. ECHOENDOSCOPYECHOENDOSCOPY7.7. COMPUTER TOMOGRAPHYCOMPUTER TOMOGRAPHY8.8. MAGNETIC RESONANCEMAGNETIC RESONANCE

ANOREXIA (A)ANOREXIA (A) In diseases of GIT and liverIn diseases of GIT and liver It may precede the jaundice in Acute It may precede the jaundice in Acute

HepatitisHepatitis Prominent symptom in gastric carcinomaProminent symptom in gastric carcinoma A A ≠ ≠ SITOPHOBIA (fear of eating because of SITOPHOBIA (fear of eating because of

subsequent abdominal discomfort)subsequent abdominal discomfort) A may be a prominent feature of A may be a prominent feature of

extraintestinal diseasesextraintestinal diseases Chronic pain from any source Chronic pain from any source →loss of →loss of

appetiteappetite In cancer, AIn cancer, A results from anxiety, pain, results from anxiety, pain,

decreased sense of taste + smell, effects of decreased sense of taste + smell, effects of the tumor on the GIT (tumor necrosis factor)the tumor on the GIT (tumor necrosis factor)

Medications:Medications: AntihypertensiveAntihypertensive DiureticsDiuretics

DigitalisDigitalis Narcotic analgesicsNarcotic analgesics

Psychogenic disturbances – A nervosaPsychogenic disturbances – A nervosa Congestive heart failure/Respiratory Congestive heart failure/Respiratory

failurefailure Endocrinopathies/hyperparathyroidism, Endocrinopathies/hyperparathyroidism,

Addison’s diseaseAddison’s disease

Mechanism of hunger + apetiteMechanism of hunger + apetiteFood intake is reglated by 2 hypotalamic Food intake is reglated by 2 hypotalamic centers:centers:

Lateral “feeding center”Lateral “feeding center” Ventromedial “satiety center”Ventromedial “satiety center” CCK (brain gut peptide) – satiety effectCCK (brain gut peptide) – satiety effect

NAUSEA AND VOMITINGNAUSEA AND VOMITING common manifestations of many common manifestations of many

organic/functional disordersorganic/functional disorders ACUTE ABDOMINAL EMERGENCIESACUTE ABDOMINAL EMERGENCIES leads to leads to

“SURGICAL ABDOMEN”“SURGICAL ABDOMEN” acute appendicitisacute appendicitis acute cholecystitisacute cholecystitis intestinal obstructionintestinal obstruction acute peritonitisacute peritonitis

DISORDERS OF THE ALIMENTARY TRACTDISORDERS OF THE ALIMENTARY TRACT peptic ulcerpeptic ulcer GI motility disordersGI motility disorders

PostvagotomyPostvagotomy DiabetusDiabetus Idiopathic gastroparesisIdiopathic gastroparesis Liver, pancreas, biliary tract disordersLiver, pancreas, biliary tract disorders

VIRAL, BACTERIAL, PARASITIC INFECTIONS OF VIRAL, BACTERIAL, PARASITIC INFECTIONS OF THE ITTHE IT

ACUTE SYSTEMIC INFECTIONS ACUTE SYSTEMIC INFECTIONS – – young childrenyoung children

→→ FEVER FEVER CENTRAL NERVOUS SYSTEM DISORDERSCENTRAL NERVOUS SYSTEM DISORDERS

neoplasmsneoplasms encephalitisencephalitis Meniere’s diseaseMeniere’s disease migraine headachesmigraine headaches acute meningitisacute meningitis

ACUTE MYOCARDIAL INFARCTIONACUTE MYOCARDIAL INFARCTION CONGESTIVE HEART FAILURECONGESTIVE HEART FAILURE

CANCER CANCER – patients terminally ill– patients terminally ill METABOLIC + ENDOCRINOLOGIC DISORDERSMETABOLIC + ENDOCRINOLOGIC DISORDERS HYPEREMESIS GRAVIDARUMHYPEREMESIS GRAVIDARUM

SIDE EFFECTS OF DRUGS:SIDE EFFECTS OF DRUGS: digitalisdigitalis morphinemorphine chemotherapeutic agentschemotherapeutic agents ingestion of a toingestion of a toxicxic (food poisoning) (food poisoning)

PHYCHOGENIC VOMITING:PHYCHOGENIC VOMITING: anorexia nervosa, bulimiaanorexia nervosa, bulimia

Relationship of vomiting (V) to eating → Relationship of vomiting (V) to eating → diagnosticdiagnostic

V that occurs in the morningV that occurs in the morning:: pregnancy, uremia pregnancy, uremia Alcoholic gastritis – early-morning retching, emesisAlcoholic gastritis – early-morning retching, emesis

V shortly after eatingV shortly after eating → peptic ulcer + pylorospasm → peptic ulcer + pylorospasm V 4-6 h after eatingV 4-6 h after eating → pyl → pylororic obstruction, ic obstruction,

esophageal esophageal disorders (achalasia, Zenker’s disorders (achalasia, Zenker’s diverticulum)diverticulum)

Relief of abdominal pain with vomitingRelief of abdominal pain with vomiting → peptic → peptic ulcerulcer

rarrareely satietyly satiety → gastroparesis→ gastroparesis

INDIGESTIONINDIGESTION represents a challenging + difficult represents a challenging + difficult

diagnostic problem because of its diagnostic problem because of its nonspecific naturenonspecific nature

Abdominal painAbdominal pain – evaluated with Rx, – evaluated with Rx, imaging studies of the esophagus, stomach, imaging studies of the esophagus, stomach, small intestine, colon, pancreas,biliary tract.small intestine, colon, pancreas,biliary tract. ESOPHAGOGASTROSCOPYESOPHAGOGASTROSCOPY ERCPERCP COLONOSCOPYCOLONOSCOPY

Empiric trials of antiacids, HEmpiric trials of antiacids, H22-Rblocking drugs or -Rblocking drugs or sucralfat are used in patients < 40 years with sucralfat are used in patients < 40 years with epigastric painepigastric pain

SDE- persistent symptoms despite therapy/recur SDE- persistent symptoms despite therapy/recur soon after discontinued therapysoon after discontinued therapy

H pylori patientsH pylori patients – oral AB 7 days after SDE + biopsy – oral AB 7 days after SDE + biopsy Excessive gas, bloating, distension, flatulence Excessive gas, bloating, distension, flatulence → questionary: dietary → questionary: dietary

preferencespreferences

relation of symptoms to specific foodsrelation of symptoms to specific foods Elimination of milk, legumes from the diet → confirmatoryElimination of milk, legumes from the diet → confirmatory

NONULCER DYSPEPSIA-disturbances of GI motilityNONULCER DYSPEPSIA-disturbances of GI motility

Esophagus-Substernum,epigastrium-Peptic esophagitis,stricture,esophageal Esophagus-Substernum,epigastrium-Peptic esophagitis,stricture,esophageal spasm,carcinomaspasm,carcinoma

Stomach-Epigastrium-Gastritis,gastric ulcer,carcinomaStomach-Epigastrium-Gastritis,gastric ulcer,carcinoma

Duodenum1+2-Epigastrium-Duodenal ulcerDuodenum1+2-Epigastrium-Duodenal ulcer

Small intestine-Periombilical-Enteritis,lymphoma,obstructionSmall intestine-Periombilical-Enteritis,lymphoma,obstruction

Gallbladder,pancreas,liver-Epg.,right,left upper qt.,back-Gallbladder,pancreas,liver-Epg.,right,left upper qt.,back-Cholelithiasis,Pancreatitis,Hepatitis,Cirrhosis,carcinoma.Cholelithiasis,Pancreatitis,Hepatitis,Cirrhosis,carcinoma.

Colon-below umbilicus-Colon-below umbilicus-UC,carcinoma,obstructionUC,carcinoma,obstruction

Non-ulcer dyspepsia-20-30% of populationNon-ulcer dyspepsia-20-30% of population

Helicobacter pylori + chronic gastritisHelicobacter pylori + chronic gastritis Heartburn (pyrosis):Heartburn (pyrosis):

reflux of acid/bile into the esophagusreflux of acid/bile into the esophagus after a large mealafter a large meal in supinein supine Fluid in the mouth: Fluid in the mouth: salty (“water brash”)salty (“water brash”)

sour (gastric contents)sour (gastric contents)

bibittter green/yellow (bile)ter green/yellow (bile) After citrus fruit juices, drugs (alcohol, After citrus fruit juices, drugs (alcohol,

aspirin) aspirin)

Food intoleranceFood intolerance Carcinoma -discomfort for solidsCarcinoma -discomfort for solids Citrus ↓ pH Citrus ↓ pH → → peptic ulcer, esophagitispeptic ulcer, esophagitis Deficiency of a specific enzyme (lactase-milk)Deficiency of a specific enzyme (lactase-milk)

abdominal crampsabdominal cramps distentiondistention diarrheadiarrhea fflatulencelatulence

Allergic reactions – urticaria, angioedema, Allergic reactions – urticaria, angioedema, asthmaasthma

Toxic effects – gluten in celiac sprueToxic effects – gluten in celiac sprue History of fatty food intolerance or distress History of fatty food intolerance or distress

after spicy foods is commonly in patients after spicy foods is commonly in patients with indigestion with indigestion

ERUCTATION (BELCHING)ERUCTATION (BELCHING) Chronic anxietyChronic anxiety Rapid eatingRapid eating Drinking carbonated beveragesDrinking carbonated beverages Gum chewingGum chewing Postnasal dripPostnasal drip Poorly fitting denturesPoorly fitting dentures 20-60% of intestinal gas is swallowed air20-60% of intestinal gas is swallowed air gastric bubble syndromegastric bubble syndrome splenic flexure syndrome-fullness in left upper splenic flexure syndrome-fullness in left upper

quadrant with radiation to the left side of the quadrant with radiation to the left side of the chestchest

↑↑ tympany + air in the splenic flexure of the tympany + air in the splenic flexure of the colon on a plain abdominal radiographcolon on a plain abdominal radiograph

GASEOUSNESS, BLOATING, GASEOUSNESS, BLOATING, FLATULENCEFLATULENCE

1.1. Motility disturbancesMotility disturbances2.2. Fermentative action of intestinal bacteria or Fermentative action of intestinal bacteria or

carbohydrates and proteins within the lumencarbohydrates and proteins within the lumen

COCO2 small intestine2 small intestine → HCl, ingested fatty acids are → HCl, ingested fatty acids are neutralized by bicarbonateneutralized by bicarbonate1/3 of adults produce methane in the colon 1/3 of adults produce methane in the colon unrelated to food ingestionunrelated to food ingestion

Ex. BeansEx. Beans contain olig contain oligoosaccharides that saccharides that can’t be split by intestinal mucosal enzymes, can’t be split by intestinal mucosal enzymes, but are metabolised by colonic bacteriabut are metabolised by colonic bacteria

Increased intraluminal gasIncreased intraluminal gas may result from may result from abnormal bacterial colonization of the small abnormal bacterial colonization of the small intestine or infection with Giardia lamblia intestine or infection with Giardia lamblia

WEIGHT GAINWEIGHT GAIN CAUSES OF OBESITYCAUSES OF OBESITY

Excess caloric intakeExcess caloric intake Cushing’s syndromeCushing’s syndrome HypothyroidismHypothyroidism HypogonadismHypogonadism Insulin-secreting tumorsInsulin-secreting tumors Cranyopharyngioma (disense of Cranyopharyngioma (disense of

hypotalamus)hypotalamus)WEIGHT LOSSWEIGHT LOSS

more often a diagnostic problem than more often a diagnostic problem than weight gain, a sign of serious organic weight gain, a sign of serious organic illness.illness.

DIABETES MELLITUSDIABETES MELLITUS ↑↑ insulin-dependent form (insulin deficiency + insulin-dependent form (insulin deficiency +

↑↑ glucagon) cause accelerated proteolysis and glucagon) cause accelerated proteolysis and lipolysis → net energy state is cataboliclipolysis → net energy state is catabolic

Weight loss is associated with increased food Weight loss is associated with increased food intakeintake

ENDOCRINE DISEASEENDOCRINE DISEASE THYROTOXICOSISTHYROTOXICOSIS PHEOCHROMOCYTOMA → catecholamine PHEOCHROMOCYTOMA → catecholamine

releaserelease PANHYPOPITUITARISMPANHYPOPITUITARISM ADRENAL INSUFFICIENCY → cortisol ADRENAL INSUFFICIENCY → cortisol

deficiencydeficiency

GASTROINTESTINAL DISEASEGASTROINTESTINAL DISEASE Inflammatory bowel diseaseInflammatory bowel disease ParasitesParasites Esophageal stricturesEsophageal strictures Chronic peptic ulcerChronic peptic ulcer Pernicious anemiaPernicious anemia Cirrhosis liverCirrhosis liver

INFECTIONINFECTIONTuberculosisTuberculosisFungal diseaseFungal diseaseAmoebic abcessAmoebic abcessSubacute bacterial endocarditisSubacute bacterial endocarditisHIVHIV Cause: inflammatory cytokinesCause: inflammatory cytokines

MALIGNANCYMALIGNANCY GITGIT PancreasPancreas LiverLiver LymphomaLymphoma LeukemiaLeukemia

PSYCHIATRIC DISEASEPSYCHIATRIC DISEASE SchizophreniaSchizophrenia DepressionDepression

RENAL DISEASERENAL DISEASE

GASTROINTESTINAL GASTROINTESTINAL BLEEDINGBLEEDING- etiology -- etiology -

Upper GI BleedingUpper GI Bleeding

Peptic ulcerPeptic ulcer GastritisGastritis VaricesVarices Mallory-Weiss Mallory-Weiss

syndromesyndrome Gastric carcinomaGastric carcinoma LymphomaLymphoma PolypsPolyps Dyscrasias, vasculitisDyscrasias, vasculitis

Lower GI BleedingLower GI Bleeding

Anal + rectal lesionsAnal + rectal lesions Colonic lesions, Colonic lesions,

carcinoma, carcinoma, angiodysplasia, UC, angiodysplasia, UC, ischemic colitisischemic colitis

Diverticula Meckel’s Diverticula Meckel’s congenital distal congenital distal ileum – 2%ileum – 2%

HISTORYHISTORY

Ulcer diseaseUlcer disease Recent heavy use of alcohol/AIND → Recent heavy use of alcohol/AIND →

erosive gastritis, esophageal variceserosive gastritis, esophageal varices Aspirin → gastroduodenitisAspirin → gastroduodenitis

peptic ulceration bleedingpeptic ulceration bleeding Acute onset of bloody diarrhea → IBDAcute onset of bloody diarrhea → IBD

PHYSICAL EXAMPHYSICAL EXAM DERMATOLOGICDERMATOLOGIC

telangiectasia Osler-Weber-Rendutelangiectasia Osler-Weber-Rendu perioral pigmentation of Peutz-Jeghersperioral pigmentation of Peutz-Jeghers diffuse pigmentation hemochromatosisdiffuse pigmentation hemochromatosis spider angiomataspider angiomata gynecomastiagynecomastia testicular atrophytesticular atrophy jaundicejaundice ascitesascites hepatosplenomegaly – HTP hepatosplenomegaly – HTP → → varicesvarices abdominal mass abdominal mass → → malignancymalignancy

RECTAL EXAMINATION RECTAL EXAMINATION → → local pathologylocal pathology

color of the stoolcolor of the stool

LAB STUDIESLAB STUDIES Hb, Ht, WC, IPHb, Ht, WC, IP Radiography of the abdomen → perforation, ischemiRadiography of the abdomen → perforation, ischemiaa is suspected is suspected Repeated evaluation of the lab data-clinical course of the bleeding.Repeated evaluation of the lab data-clinical course of the bleeding.

CONSTIPATION and DIARRHEACONSTIPATION and DIARRHEA -functional and organic disorders-functional and organic disorders IRRITABLE BOWEL,colonic tumors,IBD,mucosal disorders ,sprue,pancreatic insufficiency,postgastrectomy,endocrine diseases,habitual.IRRITABLE BOWEL,colonic tumors,IBD,mucosal disorders ,sprue,pancreatic insufficiency,postgastrectomy,endocrine diseases,habitual.

DIAGNOSTICDIAGNOSTIC

ENDOSCOPY:ENDOSCOPY: diagnosticdiagnostic treatment: coagulation Nd-treatment: coagulation Nd-

YAG laser, YAG laser, elecrocautery, elecrocautery, sclerotherapy of varicessclerotherapy of varices

ANGIOGRAPHY:ANGIOGRAPHY: localise the site of bleedinglocalise the site of bleedingintraarterial infusions of intraarterial infusions of

vasoconstrictor vasoconstrictor agents/vasopressinagents/vasopressin

COLONOSCOPY:COLONOSCOPY: GI bleeds, GI bleeds,polypectomy/polypectomy/

electrocoagulationelectrocoagulation Barium enemaBarium enema – limited role – limited role ArteriographyArteriography – active blood loss > 0,5 – active blood loss > 0,5

ml/minml/min Bleeding scansBleeding scans