CLINICAL FEATURES and INVESTIGATIONS in GASTROENTEROLOGY

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

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

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

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

ZENKER’S DIVERTICULUM 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 ACHALASIA ZENKER’S DIVERTICULUM GERD laryngitis secondary GER

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 Prolonged nasogastric intubation Ingestion of caustic agents Previous radiation therapy causes of esophageal strictures

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

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

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)

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

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

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

Relationship of vomiting (V) to eating → diagnostic 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

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

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.

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)

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

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

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

WEIGHT GAIN WEIGHT LOSS 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.

DIABETES MELLITUS ENDOCRINE DISEASE ↑ 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

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

MALIGNANCY PSYCHIATRIC DISEASE RENAL DISEASE GIT Pancreas Liver Lymphoma Leukemia PSYCHIATRIC DISEASE Schizophrenia Depression RENAL DISEASE

GASTROINTESTINAL BLEEDING - etiology - 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%

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

PHYSICAL EXAM DERMATOLOGIC RECTAL EXAMINATION → local pathology 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

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,colonic tumors,IBD,mucosal disorders ,sprue,pancreatic insufficiency,postgastrectomy,endocrine diseases,habitual.

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