REVISION CLASS

ON
GASTROINTESTINAL
DISORDERS
DR. AMIT WAZIB
FCPS (MEDICINE), MD (NEUROLOGY)
ASSOCIATE PROFESSOR & HEAD
DEPARTMENT OF MEDICINE
SHAHABUDDIN MEDICAL COLLEGE
 UPPER ABDOMINAL PAIN
EPIGASTRIC RIGHT
 PEPTIC ULCER HYPOCHONDRIAC
DISEASE  CHOLECYSTITIS
 CARCINOMA  LIVER ABSCESS
STOMACH  VIRAL HEPATITIS
 PANCREATITIS
 ACUTE INFERIOR
MI
 NON ULCER
DYSPEPSIA
 ACUTE UPPER ABDOMINAL
PAIN
EPIGASTRIC RIGHT
 PEPTIC ULCER HYPOCHONDRIAC
DISEASE  ACUTE
 ACUTE CHOLECYSTITIS
PANCREATITIS  LIVER ABSCESS
 ACUTE INFERIOR  VIRAL HEPATITIS
MI
 CHRONIC UPPER
ABDOMINAL PAIN
EPIGASTRIC RIGHT
 PEPTIC ULCER HYPOCHONDRIAC
DISEASE  CHRONIC
 CARCINOMA CHOLECYSTITIS
STOMACH
 CHRONIC
PANCREATITIS
 NON ULCER
DYSPEPSIA
 ACUTE UPPER ABDOMINAL
PAIN
EPIGASTRIC RIGHT
 PEPTIC ULCER HYPOCHONDRIAC
DISEASE  ACUTE
 ACUTE CHOLECYSTITIS
PANCREATITIS  LIVER ABSCESS
 ACUTE INFERIOR  VIRAL HEPATITIS
MI
 ACUTE UPPER ABDOMINAL
PAIN :
CLINICAL
DIFFERENTIAL HISTORY
EVALUATION
CLINICAL
DIAGNOSES EXAMINATION
PEPTIC ULCER RECURRENT EPIGASTRIC
DISEASE (WITH OR EPIGASTRIC PAIN TENDERNESS
WITHOUT RELATION WITH IN PERFORATION:
PERFORATION) MEAL RIGIDITY
PARTALLY RELIEVED REBOUND
WITH ANTACIDS TENDERNESS
ACUTE PANCREATITIS VOMITING EPIGASTRIC
ALCOHOLISM TENDERNESS
CULLEN’S SIGN
GREY TURNER’S
SIGN
ACUTE INFERIOR MI ELDERLY NO EPIGASTRIC
VOMITING TENDERNES
SWEATING FALLING BP
BRADYCARDIA
 ACUTE UPPER ABDOMINAL
PAIN :
CLINICAL
DIFFERENTIAL HISTORY
EVALUATION
CLINICAL
DIAGNOSES EXAMINATION
ACUTE PAIN IN RIGHT RIGHT
CHOLECYSTITIS HYPOCHONDRIUM HYPOCHONDRIAC
RADIATING TO RIGHT TENDERNESS
SHOULDER POSITIVE MURPHY’S
SIGN

LIVER ABSCESS HIGH GRADE FEVER TENDER

WITH CHILLS AND HEPATOMEGALY
RIGOR
PAIN IN RIGHT
HYPOCHONDRIUM
ACUTE VIRAL JAUNDICE TENDER
HEPATITIS VOMITING HEPATOMEGALY
ANOREXIA JAUNDICE
 ACUTE UPPER ABDOMINAL
PAIN :
INVESTIGATIONS
INVESTIGATIONS
FINDING INTERPRETATION
ULTRASONOGRAM OF SWOLLEN PANCREAS ACUTE
ABDOMEN PANCREATITIS
ECHOGENIC ACUTE
STRICTURES WITHIN CHOLECYSTITIS
GALL BLADDER
ROUNDED LIVER ABSCESS
HYPOECHOIC LESION
WITHIN LIVER
PLAIN X-RAY GAS UNDER PERFORATED
ABDOMEN IN ERECT DIAPHRAGM PEPTIC ULCER
POSTURE
ECG ST ELEVATION, T ACUTE INFERIOR MI
INVERSION,
PATHOLOGICAL Q IN
LEAD II, III AND aVF
SERUM LIPASE AND RAISED ACUTE
 CHRONIC UPPER
ABDOMINAL PAIN
EPIGASTRIC RIGHT
 PEPTIC ULCER HYPOCHONDRIAC
DISEASE  CHRONIC
 CARCINOMA CHOLECYSTITIS
STOMACH
 CHRONIC
PANCREATITIS
 NON ULCER
DYSPEPSIA
 CHRONIC UPPER ABDOMINAL
PAIN :
CLINICAL
DIFFERENTIAL HISTORY
EVALUATION
CLINICAL
DIAGNOSES EXAMINATION
PEPTIC ULCER RECURRENT EPIGASTRIC
DISEASE EPIGASTRIC PAIN TENDERNESS
RELATION WITH
MEAL
PARTALLY RELIEVED
WITH ANTACIDS
CARCINOMA ELDERLY EPIGASTRIC MASS
STOMACH DYDPESIA
PAIN NOT RELIEVED
WITH ANTACIDS
WEIGHT LOSS
CHRONIC RECURRENT EPIGASTRIC
PANCREATITIS EPIGASTRIC PAIN TENDERNESS
WEIGHT LOSS SIGNS OF
STEATORRHEA MALABSORPTION
DIABETES
 CHRONIC UPPER ABDOMINAL
PAIN :
CLINICAL
DIFFERENTIAL HISTORY
EVALUATION
CLINICAL
DIAGNOSES EXAMINATION
NON ULCER RECURRENT NO EPIGASTRIC
DYSPEPSIA EPIGASTRIC PAIN TENDERNESS OR
NO WEIGHT LOSS MASS

CHRONICCHOLECYSTI RECURRENT PAIN IN RIGHT

TIS RIGHT HYPOCHONDRIAC
HYPOCHONDRIUM TENDERNESS
RADIATING TO RIGHT
SHOULDER
 CHRONIC UPPER ABDOMINAL
PAIN :
INVESTIGATIONS
INVESTIGATIONS
FINDING INTERPRETATION
ULTRASONOGRAM OF CALCIFICATION WITHIN CHRONIC
ABDOMEN PANCREAS PANCREATITIS
ECHOGENIC CHRONIC
STRICTURES WITHIN CHOLECYSTITIS
THICK WALLED GALL
BLADDER
PLAIN X-RAY CALCIFICATION WITHIN CHRONIC
ABDOMEN PANCREAS PANCREATITIS

ENDOSCOPY OF ULCER IN DUODENUM PEPTIC ULCER

UPPER GIT (WITH DISEASE
BIOPSY)
ULCER IN STOMACH PEPTIC ULCER
WITHOUT MALIGNANT DISEASE
CELL
ULCER / FINGATING CARCINOMA
GROWTH IN STOMACH STOMACH
 PEPTIC ULCER DISEASE
SYMPTOMS
RECURRENT

EPIGASTRIC PAIN
RELATED WITH MEAL
[WORSENS WITH MEAL – GASTRIC ULCER
MORE IN EMPTY STOMACH – DUODENAL ULCER]
PARTIALLY RELIEVED BY ANTACIDS

HEART BURN
WATER BRUSH

SIGN
EPIGASTRIC TENDERNESS
 PEPTIC ULCER DISEASE
INVESTIGATION

1. ENDOSCOPY OF UPPER GASTRO-

INTESTINAL TRACT

2. TEST FOR H. PYLORI

 UREA BREATH TEST
 FEACAL ANTIGEN TEST
 PEPTIC ULCER DISEASE :
COMPLICATION
ACUTE
 HAEMORRHAGE
 PERFORATION

CHRONIC
 GASTRIC OUTLET OBSTRUCTION
[PYLORIC STENOSIS]
 CARCINOMA STOMACH
PEPTIC ULCER DISEASE :
TREATMENT
ERADICATION OF H. PYLORI
2 ANTIMICROBIAL + 1 PROTON PUMP
INHIBITOR FOR 7 DAYS

ANTIBIOTIC (ANY TWO) : TWICE DAILY

CLARITHROMYCIN 500 mg*
AMOXYCILLIN 1 g*
METRONIDAZOLE 400 mg

PPI : TWICE DAILY

CARCINOMA STOMACH :
HISTORY
SYMPTOMS
ELDERLY
DYSPEPSIA
EPIGASTRIC PAIN
WEIGHT LOSS
 CARCINOMA STOMACH :
HISTORY
RISK FACTORS
PEPTIC ULCER DISEASE
DIET : SALTED SMOKED FOOD
SMOKING
FAMILY HISTORY OF GI MALIGNANCIES
CARCINOMA STOMACH :
CLINICAL EXAMINATION
CACHEXIA
ANAEMIA
EPIGASTRIC LUMP***
SCALENE LYMPHADENOPATHY
HEPATOMEGALY
 CARCINOMA STOMACH :
INVESTIGATION
DIAGNOSTIC
ENDOSCOPY OF UPPER GASTRO-
INTESTINAL TRACT WITH BIOPSY
FOR HISTOPATHOLOGY

FOR STAGING
 ULTRASONOGRAM OF ABDOMEN
 CHEST X-RAY
 CARCINOMA STOMACH :
TREATMENT
TREATMENT IS MULTIDISCIPLINARY,
TO BE FINALIZED BY THE COMBINED
DECISION BY PHYSICIAN, SURGEON
AND ONCOLOGIST.

LIMITED DISEASE IS TREATED BY

SURGERY WITH CHEMOTHERAPY.

ADVANCED DISEASE IS TREATED

WITH CHEMOTHERAPY.
 GI HAEMORRHAGE
SITE OF APPEARANCE NOMENCLATUR
BLEEDING E

STOMACH TO ACUTE HAEMATEMESIS

MID VOMITING OF COFFEE
TRANSEVERSE GROUND BLOOD
COLON CHRONIC MELAENA
BLACK TARRY STOOL

DISTAL RED BLOOD MIXED WITH HAEMATOCHEA

TRANSVERSE STOOL ZIA
COLON TO
SIGMOID COLON
 ACUTE UPPER GI
HAEMORRHAGE
PRESENTATION
HAEMATEMESIS AND MELAENA

CAUSES
1. DRUG (NSAID) INDUCED GASTRIC
EROSION
2. BLEEDING PEPTIC ULCER
3. RUPTURED OESOPHAGEAL VARICES
4. CARCINOMA STOMACH
5. BLEEDING ABNORMALITY (ITP, ACUTE
LEUKAEMIA, APLASTIC ANAEMIA,
DENGUE, ANTICOAGULANT)
 ACUTE UPPER GI
HAEMORRHAGE
MANAGEMENT
PRINCIPLES
1. RESUSCITATION
2. DETECTION OF CAUSE
3. CONTROL OF BLEEDING
 ACUTE UPPER GI
HAEMORRHAGE
MANAGEMENT
RESUSCITATION
MEDICAL EMERGENCY, MUST BE ADMITTED.
1. INTRAVENOUS ACCESS
2. OXYGEN THERAPY
3. INTRAVENOUS CRYSTALLOIDS
4. INTRAVENOUS PROTON PUMP INHIBITOR
5. INITIAL INVESTIGATIONS
 CBC
 BLOOD GROUPING
 PROTHROMBIN TIME
 SERUM CREATININE
6. BLOOD TRANSFUSION
ACUTE UPPER GI HAEMORRHAGE
MANAGEMENT
DETECTION OF CAUSE: CLINICAL
CAUSE HISTORY EXAMINATION
EVALUATION
DRUG INDUCED RECENT NSAID
GASTRIC EROSION USE
BLLEDING PEPTIC RECURRENT EPIGASTRIC
ULCER EPIGASTRIC PAIN TENDERNESS
CARCINOMA STOMACH ELDERLY EPIGASTRIC LUMP
DYSPEPSIA
WEIGHT LOSS
RUPTURED JAUNDICE STIGMATA OF CLD
OESOPHAGEAL VARICES
BLEEDING BLEEDING FROM GENERALIZED
ABNORMALITY OTHER SITES LYMPHADENOPATHY
FEVER HEPATOMEGALY
ANTICOAGULANT SPLENOMEGALY
USE BONY TENDERNESS
ACUTE UPPER GI HAEMORRHAGE
MANAGEMENT
DETECTION OF CAUSE:
INVESTIGATIONS

MANDATORY INVESTIGATION
ENDOSCOPY OF UPPER GASTRO-
INTESTINAL TRACT

SELECTIVE INVESTIGATIONS
LIVER FUNCTION TESTS
ULTRASONOGRAM OF ABDOMEN
ACUTE UPPER GI HAEMORRHAGE
MANAGEMENT
CONTROL OF BLEEDING
1. ENDOSCOPIC PROCEDURE :
 VARICEAL LIGATION
 SCLEROTHERAPY
 LASER THERAPY
 DIATHERMY
 CLIPPING

2. SURGICAL CONSULTATION WHEN

BLEEDING CONTINUES DESPITE
ENDOSCOPIC THERAPY.

3. TREATMENT OF CAUSE.
 CHRONIC DIARRHOEA
1. INTESTINAL TUBERCULOSIS
2. INFLAMMATORY BOWEL DISEASE
3. MALABSORPTION SYNDROME
4. IRRITABLE BOWEL SYNDROME
 CHRONIC DIARRHOEA :
CLINICAL EVALUATION
CAUSE POINTS IN FAVOUR

INTESTINAL ABDOMINAL PAIN

FEVER
TUBERCULOSIS WEIGHT LOSS
PULMONARY TB

INFLAMMATORY BOWEL RELAPSE AND REMISSION

ABDOMINAL PAIN
DISEASE BLOODY DIARRHOEA
JOINT PAIN

MALABSORPTION STEATORRHOEA
WEIGHT LOSS
SYNDROME SIGNS OF VITAMIN DEFICIENCIES

IRRITABLE BOWEL ABDOMINAL PAIN OR

DISCOMFORT
SYNDROME RELIEVED WITH DEFAECATION
NO WEIGHT LOSS, BLOODY
DIARRHOEA OR FEVER
 CHRONIC DIARRHOEA :
INVESTIGATION
FIRST LINE
 STOOL MICROSCOPY
 CBC
 C-REACTIVE PROTEIN
 CHEST X-RAY
 MANTOUX TEST
 CHRONIC DIARRHOEA :
INVESTIGATION
SELECTIVE

 3-DAY FAECAL FAT [FOR

MALABSORPTION]

 FAECAL CALPROTECTIN [FOR IBD]

 COLONOSCOPY WITH BIOPSY [FOR

IBD]
 IRRITABLE BOWEL
SYNDROME
 ABDOMINAL PAIN OR DISCOMFORT
IMPROVES AFTER DEFEACATION
 CONSTIPATION
 DIARRHOEA

 NO WEIGHT LOSS, FEVER OR BLOOD

WITH STOOL
 NO ABDOMINAL LUMP
IRRITABLE BOWEL SYNDROME
: INVESTIGATIONS
1. CBC : NORMAL
2. CRP : NORMAL
3. STOOL MICROSCOPY : NO RBC OR
PUS CELL
IRRITABLE BOWEL SYNDROME
: TREATMENT
ADVICE
 REASSURANCE
 TAKE ADEQUATE FIBRES AND WATER

DRUGS
 PREBIOTICS
 ANTISPASMODIC FOR PAIN
 LOPERAMIDE FOR DIARRHOEA
VARIETY
 LAXATIVES & LUBIPROSTONE FOR
CONSTIPATION VARIETY
 TRICYCLIC ANTIDEPRESSANT FOR
REFRACTORY CASES
 INFLAMMATORY BOWEL
DISEASE VERSUS
IRRITABLE BOWEL SYNDROME
INFLAMMATORY IRRITABLE BOWEL
BOWEL DISEASE SYNDROME

WEIGHT LOSS PRESENT ABSENT

BLOOD MIXED WITH PRESENT ABSENT

STOOL

FEVER PRESENT ABSENT

JOINT PAIN PRESENT ABSENT

ESR AND CRP RAISED NORMAL

STOOL MICROSCOPY RBC AND PUS CELL RBC AND PUS CELL
PRESENT ABSENT

FAECAL POSITIVE NEGATIVE