CF & Inv.

Of GIT

1
 Common GI symptoms
1. Abdominal pain
2. Heartburn
3. Nausea & vomiting
4. Altered bowel habits
5. GI bleeding
6. Jaundice

2
 Common GI symptoms (contd)
7. Dysphagia
8. Anorexia
9. Weight loss
10. Fatigue
11. Extraintestinal
symptoms

3
 Abdominal pain
• Due to GI disease/extraintestinal conditions
(genitourinary tract, abdominal wall, thorax
or spine)
• Visceral pain is vague & generally midline

4
 Abdominal pain (contd)
• Parietal pain is localized & precisely
described
• Most common causes are IBS &
functional dyspepsia

5
 Abdominal pain (contd)
1. Appendicitis
2. Gallstone
3. Pancreatitis
4. Diverticulitis
5. Ulcer disease

6
 Abdominal pain (contd)
6. Oesophagitis
7. GI Obstruction
8. IBD
9. Functional bowel disease
10. Vascular disease

7
 Abdominal pain (contd)
11. Gynaecological
12. Renal stone
13. Infectious enterocolitis
14. Mesenteric ischaemia
15. Neoplasia

8
 HEARTBURN
• Burning substernal sensation
• Results from excess gastroesophageal reflux
of acid or heightened sensitivity of
oesophageal mucosal nerves

9
 Nausea & vomiting
• GI disease
• Medications,toxins
• Acute & chronic infections
• Endocrine disorders
• Labyrinthine conditions
• CNS disease

10
 Nausea & vomiting (contd)
• Best characterized GI causes relate to
mechanical obstruction of the upper gut
• Disorders of propulsion (gastroparesis,
intestinal pseudoobstruction)
• IBS & functional dyspepsia

11
 Nausea & vomiting
1. Medications
2. GI obstruction
3. Motor disorders
4. Functional bowel disorder
5. Enteric infection
6. Pregnancy
7. Endocrine disorder
8. Motion sickness
9. CNS disease

12
 Altered bowel habit
Constipation
• Infrequent defecation
• Straining
• Passage of hard stools
• Sense of incomplete faecal evacuation

13
 Causes of constipation
• Obstruction
• Motor disorders of colon
• Medications
• Endocrine disease viz, hypothyroidism,
hyperparathyroidism

14
 Altered bowel habit (contd)
Diarrhoea:
• Frequent defaecation
• Loose or watery stools
• Faecal urgency
• Sense of incomplete evacuation

15
 Irritable bowel syndrome
• Constipation or diarrhoea
• Alternating bowel pattern
• Mucus is common in IBS,while pus is in
inflammatory disease
• Steatorrhoea develops with malabsorption

16
 Causes of diarrhoea
1. Infection
2. Poorly absorbed sugars
3. IBD
4. Microscopic colitis
5. Functional bowel disorder

17
 Causes of diarrhoea (contd)
6. Coeliac disease
7. Pancreatic insufficiency
8. Hyperthyroidism
9. Ischaemia
10. Endocrine tumour

18
 GI Bleeding
• Most commonly UGI bleed presents with
melaena or hemetemesis
• LGI bleeding produces bright red or maroon
stools
• Chronic slow GI bleed may present with
iron-deficiency anaemia

19
 GI Bleeding
1. Ulcer disease 7. Haemorrhoids
2. Oesophagitis 8. Fissures
3. Varices 9. IBD
4. Vascular lesions 10.Infectious colitis
5. Neoplasm 11.AVM
6. Diverticula

20
 JAUNDICE
• Prehepatic
• Intrahepatic
• Posthepatic

21
 Obstructive jaundice
1. Bile duct stone
2. Cholangiocarcinoma
3. Cholangitis
4. Sclerosing cholangitis
5. Ampullary stenosis
6. Ampullary carcinoma
7. Pancreatitis
8. Pancreatic tumour
22
 Other symptoms
• Dysphagia, odynophagia, unexplained chest
pain suggest oesophageal disease
• Globus sensation (oesophagopharyngeal,
functional)

23
 Other symptoms (contd)
• Weight loss, anorexia & fatigue are
nonspecific symptoms of neoplastic,
inflammatory, gut motor, pancreatic, small
bowel mucosal, & psychiatric conditions
• Fever (inflammatory illness, malignancy)

24
 GI disorders with extraintestinal
symptoms
1. IBD (hepatobiliary dysfunction,skin & eye
lesions & arthritis)
2. Coeliac disease (dermatitis herpetiformis)
3. Jaundice can produce pruritus

25
Systemic diseases with GI symptoms

1. Systemic lupus may cause gut ischaemia,

presenting with pain & bleeding
2. Overwhelming stress or burns may lead to
gastric ulcer formation

26
 Lab investigations
• Iron-deficiency anaemia (mucosal blood
loss, poor intake)
• Vit B12 deficiency (small intestinal, gastric,
pancreatic, poor intake)

27
 Lab (contd)
• Leucocytosis, increased ESR (inflammatory
conditions)
• Leucopenia (Viremic illness)

28
 Lab (contd)
• Severe vomiting/diarrhoea elicits :
a) electrolyte disturbances
b) acid-base abnormalities
c) elevated blood urea nitrogen

29
 Lab (contd)
• Elevated pancreatic or liver chemistries
• Thyroid chemistries, cortisol, calcium to
exclude endocrinologic causes of GI
symptoms

30
 Lab (contd)
• Pregnancy testing for young women with
unexplained nausea
• Serologic tests for SLE or scleroderma
• Hormone levels for suspected endocrine
neoplasia

31
 Lab (contd)
• Intraabdominal malignancies produce
tumour markers,eg,CEA
• Paraneoplastic dysmotility is associated
with antineuoronal antibodies

32
 Lab (contd)
• Ascitic fluid for infection, malignancy,
portal hypertension
• CSF for suspected CNS causes of vomiting
• Urine for carcinoid, porphyria, heavy metal
intoxication

33
 Luminal contents
• Stool for leucocytes, parasite or cultured for
bacterial pathogens

• Duodenal aspirates for parasites or cultured

for bacterial overgrowth

34
 Luminal contents (contd)
• Faecal fat quantification in malabsorption
• Stool electrolytes & osmolarity in diarrhoea
• Stool osmotic gap >100 mosmol/l, indicates
osmotic diarrhoea

35
 Luminal contents (contd)
• Laxative screens done when abuse is
suspected
• Gastric acid quantified to r/o ZES
• Oesophageal pH for refractory symptoms of
acid reflux

36
 Luminal contents (contd)
• Pancreatic juice analyzed for enzyme or
bicarbonate content to exclude pancreatic
exocrine insufficiency

37
 Plain abdominal x-ray
• Distribution of gas within the small & large
intestines
• Useful in dx of intestinal obstruction or
paralytic ileus where dilated loops of bowel
and (in the erect position) fluid levels are
seen.

38
 Plain AxR (contd)
• Outlines of soft tissues such as liver, spleen
& kidneys may be visible
• Calcification of these organs as well as
pancreas, blood vessels, lymph nodes &
calculi may be detected

39
 Plain AxR (contd)
• Abdominal X-rays do not help in cases of
GI bleeding

40
 Chest x-ray
• Shows the diaphragm
• Erect films may detect subdiaphragmatic
free air in cases of perforation
• Unexpected pulmonary problems such as
pleural effusions will also be revealed

41
 Ba swallow Indications
• Dysphagia
• Heartburn
• Chest pain
• Possible motility disorder

42
 Ba swallow uses
• Strictures
• Hiatus hernia
• Gastro-oesophageal reflux
• Motility disorders e.g. achalasia

43
 Ba swallow limitations
• Risk of aspiration
• Poor mucosal detail
• Unable to biopsy

44
 Ba meal indications
• Dyspepsia
• Epigastric pain
• Anaemia
• Vomiting
• Possible perforation (non-ionic contrast)

45
 Ba meal uses
• Gastric or duodenal ulcers
• Gastric cancer
• Outlet obstruction
• Gastric emptying disorders

46
 Ba meal limitations
• Low sensitivity for early cancer
• Unable to biopsy or assess Helicobacter
pylori

47
 Ba follow through indications
• Diarrhoea and abdominal pain of small
bowel origin
• Possible obstruction by strictures etc

48
 Ba follow through uses
• Malabsorption
• Crohn’s disease

49
 Ba follow through limitations
• Time-consuming
• Radiation exposure

50
 Ba enema indications
• Altered bowel habit
• Rectal bleeding
• Anaemia

51
 Ba enema uses
• Neoplasia
• Diverticulosis
• Strictures, e.g. ischaemic
• Megacolon

52
 Ba enema limitations
• Difficult in frail elderly or incontinent
patients
• Uncomfortable
• Sigmoidoscopy also necessary to evaluate
rectum
• Possibly misses polyps < 1 cm
• Less useful in inflammatory bowel disease
53
 USG uses
1. Abdominal masses, e.g. cysts, tumours,
abscesses
2. Organomegaly
3. Ascites
4. Biliary tract dilatation
5. Gallstones
6. Guided needle aspiration & bx of lesions
54
 USG limitations
1. Low sensitivity for small lesions
2. Little functional information
3. Operator-dependent
4. Gas & obesity may obscure view

55
 CT uses
1. Assessment of pancreatic disease
2. Hepatic tumour deposits
3. Tumour staging
4. Assessment of vascularity of lesions

56
 CT limitations
1. Expensive
2. High radiation dose
3. May understage some tumours, e.g.
oesophago-gastric

57
 MRI uses
1. Hepatic tumour staging
2. MRCP
3. Pelvic/perirenal disease
4. Crohn’s fistulae

58
 MRI limitations
1. Role in GI disease not fully established
2. Limited availability
3. Time-consuming
4. Claustrophobic for some
5. Contraindicated in presence of metallic
prosthesis, cardiac pacemaker

59
 Endoscopy
• Can provide causes of bleeding, pain, N/V,
weight loss, altered bowel function & fever
• Upper endoscopy evaluates oesophagus,
stomach & duodenum

60
 Sigmoidoscopy
• Examines the colon up to splenic flexure to
exclude distal colonic inflammn or
obstruction
• In young patients not at significant risk for
colon cancer

61
 Endoscopy (contd)

• Colonoscopy assesses the colon & distal

ileum

62
 UGIE indications
1. Dyspepsia > 55 yrs of age or with alarm
symptoms
2. Atypical chest pain
3. Dysphagia
4. Vomiting

63
 UGIE indications (contd)
5. Weight loss
6. Acute or chronic GI bleeding
7. Suspicious barium meal
8. Duodenal bx in inv. of malabsorption

64
 UGIE (contd)
9 Polypectomy
10 Place gastrostomy
11 Barrett’s metaplasia surveillance
12 Palliate neoplasm
13 Sample duodenal tissue/fluid
14 Removal of FB

65
 UGIE contraindications
1. Severe shock
2. Recent MI, unstable angina, cardiac
arrhythmia
3. Severe respiratory disease
4. Atlantoaxial subluxation
5. Possible visceral perforation

66
 UGIE complications
1. Cardiorespiratory depression due to
sedation
2. Aspiration pneumonia
3. Perforation
4. Bleeding
5. Infective endocarditis (use antibiotic
prophylaxis in those with previous
endocarditis or a prosthetic heart valve)
67
 Colonoscopy indications
1. Suspected IBD
2. Chronic diarrhoea
3. Altered bowel habit
4. Rectal bleeding or anaemia

68
Colonoscopy indications (contd)
5. Assessment of abnormal barium enema
6. Colorectal cancer screening
7. Colorectal adenoma f/u
8. Therapeutic procedures

69
 Colonoscopy CI
1. Severe, active ulcerative colitis
2. As for UGIE

70
 Colonoscopy complications
1. Cardiorespiratory depression due to
sedation
2. Perforation
3. Bleeding
4. Infective endocarditis (use antibiotic
prophylaxis in those with previous
endocarditis or a prosthetic heart valve)

71
 Reasons for bx
1. Suspected malignant lesions
2. Assessment of mucosal abnormalities
3. Diagnosis of infection (e.g. candida, H.
pylori, Giardia lamblia)
4. Measurement of enzyme contents (e.g.
disaccharidases)
5. Analysis of genetic mutations (e.g.
oncogenes, tumour suppressor genes)
72
 ERCP
1. Jaundice 7. Pancreatitis with
2. Postbiliary surgery unrelenting pain
complaints 8. Fistulas
3. Cholangitis 9. Biopsy radiologic
4. Gallstone abnormality
pancreatitis
5. Pancreatic/biliary/ 10. Pancreatiobiliary
ampullary tumour drainage
6. Unexplained 11. Sample bile
pancreatitis 12. Sphincter of Oddi
manometry
73