Gastrointestinal Disorders

UERM - COL LEGE OF AL LIED REH ABIL ITATION SC IEN CE S
MS1 DR. EJ AGSAOAY: GASTROINTESTINAL DISORDERS
Page 1 of 9
ACUTE UPPER GI BLEEDING

• Hematemesis (bright red blood or “coffee
grounds”)
• Melena in most cases; hematochezia in
massive upper gastronintestinal bleeds
• Volume status to determine severity of blood
loss, hematocrit is poor early indicator of
blood loss
• Endoscopy diagnostic and likewise
therapeutic

• Mosy common presentation of upper
gastrointestinal bleeding is hematamesis or
melenea
• Melena develops after as little as 50-
100mL of blood loss on the upper
gastrointestinal tract, wheras hematochezia
requires a loss of mroe than 1000mL
• Upper gastronintestinal bleeding is self
limited in 80% of patient ; urgent medical
therapy and endoscopic evaluation are
obligatory in the rest

Page 2 of 9

PEPTIC ULCER DISEASE EROSIVE GASTRITIS

• Account for half major upper gastronintestinal
bleeding with an overall mortality rate of 4%
• Incidence of bleeding from ulcers is declining,
perhaps due to eradication of H pylori use of
safer NSAIDS and prophylaxis with proton
pump inhibitors in high risk patients • Process is
superficial- relatively
unusual cause of severe gastrointestinal
bleeding (<5% of cases) and more
commonly results in chronic blood loss
• Gastric mucosal erosions are due to
NSAIDS, alcohol or severe medical or
surgical illness (stress gastritis)

DUODENAL ULCER WITH OOZING

NSAID INDUCED
! NGT, inserted through nose until reaches stomach
! initially start as gastritis then proceed to ulcer
EVALUATION AND MANAGEMENT
• Nasogastric tube should be placed in all
patients with suspected active upper tract
bleeding
• Aspiration of red blood of “coffee grounds”
confirms an upper gastrointestinal source of
bleeding, though 10% of patients with
GASTRITIS confirmed upper tract sources of bleeding
have nonbloody aspirates-especially when
bleeding originates in the duodenum
• Erythromycin (250g) administered
intravenously 30 minutes prior to upper
endoscopy promotes gastric emptying of
clots and improves quality of endoscopic
examination
Page 3 of 9
• Periodic reaspiration of the nasogastric
tube serves as an indicator of ongoing HISTORY AND PE
bleeing or rebleeding • Physician’s impression of the bleeding
source is correct in only 40% of cases
• Signs of chronic liver disease implicate
bleeding due to portal hypertension
• History of dyspepsia, NSAID use, or peptic
ulcer disease suggests peptic ulcer
• Acute bleeding preceded by heavy alcohol
ingestion or retching suggests a Mallory-
Weiss tear (tear in mucosal layer at junction
of esophagus and stomach tear that is MW
tear)

SUBSEQUENT EVALUATION AND TREATMENT
• Hx & PE

• Upper endoscopy
• Pharmacologic intervention
• Other tx

Page 4 of 9
DIVERTICULOSIS
• Hemorrhage occurs in 3-
5% of all patients with
diverticulosis and is
most common cause of
major lower tract
bleeding, accouting for
50% of cases (see endosocopy)
• Significcant percentage of cases are
associated with the use of non steroidal
anto-inflammatory agents
• Diverticular bleeding usually presents as
acute, painless, large volume maroon or
bright red hematochezua In patients over
age 50 years
UNCOMPLICATED
DIVERTICULOSIS

Page 5 of 9
INFLAMMATORY BOWEL DISEASE
• Patients with inflammatory bowel disease

(especially ulcerative colitis) often have
diarrhea with variable amounts of
hematochezia
• Bleeding varies from occult blood loss to
recurrent hematochezia usually mixed with
stool
• Symptoms of abdominal pain, tenesmus and
urgency are often present
• Anorectal disease
ANORECTAL DISEASE
• Commonly results in small amounts of
bright red blood noted on toilet laper,
streaking of stool, or dripping into toilet
bowl
• Bleeding is slight and seldom results in
significant blood loss
• Painless bleedings is commonly caused by
internal hemorrhoids
• Bleeding associated with painful bowel
movement suggests as anal fissure
INTERNAL
HEMORRHOIDS
Page 6 of 9
ASCITES GASTROESOPHAGEAL REFLUX DISEASE (GERD)

• Denotes the pathologic accumulation of
fluid in peritoneal cavity • Heartburn; may be exacerbated by meals,
• Healthy men have little or no interperitoneal bending or recumbency
fluid but for women they normally have up • Typical uncomplicated cases do not require
to 20ml depends on phase of menstrual diagnostic studies
cycle • Endoscopy demonstrates abnromalities in <
• Most common cause ascites : portal 50% of patients
hypertension secondary to chronic liver • Barium esophagroppahy may be helpful
disases, which accounts for over 80% of
patients with ascites
• Most common causes of non portal
hypertensive ascites include infections
(tuberculous peritonitis), intra abdominal
malignancy, inflammatory disorders of the
peritoneum and ductal disruptions
( chylopylorus, pancratic ,biliary)

Page 7 of 9
SIGNS and SYMPTOMS

EROSIVE AND HEMORRHAGIC GASTRITIS
• Epigastric pain (dyspepsia) the hallmark of

• Most common cause of erosive gastropathy peptic ulcer disease, is present in 80-90%
are drugs (especially NSAIDS) alcohol, of patients
stress due to severe medical or surgical • Clinical history cannot accurately
illness, and portal hypertension (“portal distinguish duodenal from gastric ulcers
gastropathy”) • Described as gnawing, dull, aching, and
• Uncommon causes include caustic hunger like.
ingestion and radiation • 50% of patients report relief of pain with
• Erosive and hemorrhagic gastropathy food or antacids (especially duodenal
typically and diagnosed at endoscopy, ulcers) and a recurrence of pain 2-4 hours
often being performed because of later
dyspepsia or upper gastrointestinal
bleeding
PEPTIC ULCER DISEASE

• Ulcers occur slightly more coomonly in men
than in women (1:3:1)
• Duodenal ulcers most commonly occurs in
patients between the ages 30 and 55 years
• Gastric ulcers are more common in patients
between the ages of 55 and 70 years
• Ulcers are more common in smokers and in
patients taking NSAIDS on a long term
basis
Page 8 of 9
SIGNS AND SYMPTOMS

• Usually begins with vague, often colicky
periumbilical or epigastric pain
• Within 12 hours the pain shifts to right lower
quadrant, manifested as steady ache that is
worsened by walking or coughing
• Almost all patients have nausea wkth one or
teo episodes of vomitng
• Sense of constipation is typical and some
patients adminster catharctics in an effort to
relive their symptoms – though some report
diarrhea
APPENDICITIS • Low grade fever (<38 C) is typical
• Most comon abdominal surgical
emergency,affecting approximately 10% of
population
• Occurs most commonly between the ages of
10 and 30 years
• Initiated by obstruction of the appendix by
fecailth inflammation, foreign body or
neoplasm
• Obstructions leads to increased intraluminal
pressure, venous congestion, infection
and thrombosis of intramural vessels
• If untreated, gangrene and perforation develop
within 36 hours
PE
• Localized tenderness with guarding in right
lower quadrant and can be elicited with
gentle palpation with 1 finger
• When asked to cough patients may be able
to precisely localize the painful area, a sign
of peritoneal irritation
• Psoas sign and obturator signs (pain on
pasive extension of the right hip) and
obturator sign (pain with passive flexion and
internal rotation or right hip) are indicative of
adjacent inflammation and strongly
suggestive of appendicitis
Page 9 of 9
INFLAMMED APPENDIX
ANTIBIOTIC ASSOCIATED COLITIS

• Diarrhea occurs during the period of antibiotic
exposure, is dose related and resolves
spontaneously after discontinuation of the
antobiotic
• In most cases, this diarrhea is mild, self
limited and does not require any specific
laboratory evaluation or treatment
• Stool examination usually reveals no fecal
leukocytes and stool cultures reveal no
pathogens
• Most commonly develops after use of

ampiciilin clindamycinm Third generation
cephalosporins and fluororquinolones
• Elderly debiliated, immunocompromised,
receieving Multipl antibiotics or prolonged (>10
days)
• antiobiotic therapy, receiving enteral tube
feedings or proton pump inhibitors or who have
gastrointestinal tract disease or surgery have a
higher risk of aquiring C difficile and developing
C defficile associated diarrhea

Gastrointestinal Disorders

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Gastrointestinal Disorders

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UERM - COL LEGE OF AL LIED REH ABIL ITATION SC IEN CE S

MS1 DR. EJ AGSAOAY: GASTROINTESTINAL DISORDERS

ACUTE UPPER GI BLEEDING

PEPTIC ULCER DISEASE EROSIVE GASTRITIS

DUODENAL ULCER WITH OOZING

INFLAMMATORY BOWEL DISEASE

• Patients with inflammatory bowel disease

ASCITES GASTROESOPHAGEAL REFLUX DISEASE (GERD)

SIGNS and SYMPTOMS

• Epigastric pain (dyspepsia) the hallmark of

PEPTIC ULCER DISEASE

SIGNS AND SYMPTOMS

ANTIBIOTIC ASSOCIATED COLITIS

• Most commonly develops after use of

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