ALTERATION IN GASTROINTESTINAL FUNCTION
TERMINOLOGIES
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Abdominal Pain
Key components of the Patient’s history
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Age
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Time and mode of onset of pain
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Pain characteristics
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Duration of symptoms
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Location of pain and sites of radiation
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Associated symptoms and their relationship to pain
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Nausea, emesis, anorexia
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Diarrhea, constipation
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Menstrual history
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Important causes of Abdominal Pain:
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Pain originating in the abdomen
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Parietal peritoneal inflammation
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Mechanical obstruction of hollow viscera, small & large
intestine, biliary tree, and ureter
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Vascular disturbances (Embolism, Thrombosis)
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Abdominal wall (Trauma or Infection of muscles)
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Pain referred from extra abdominal sources
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Metabolic cause (Diabetes/Uremia)
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Neurologic/Psychiatric causes (Herpes-zoster, Spinal
Cord compression)
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Toxic causes (Lead poisoning, Animal bites)
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Uncertain causes (Narcotic withdrawal, Heat Stroke)
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[ZRC]
PHYSIOLOGY OF SWALLOWING
voluntary (oral) phase that includes salivation and
mastication
transfer phase during which the bolus is pushed into
the pharynx by the tongue.
Bolus entry into the hypopharynx initiates the
pharyngeal swallow response, propel food through the
pharynx into the esophagus while preventing its entry
into the airway.
the larynx is elevated and pulled forward, actions that
also pulsion then propels the bolus through the UES
followed by a peristaltic contraction that clears residue
from the pharynx and through the esophagus.
The lower esophageal sphincter (LES) relaxes as the
food enters the esophagus and remains relaxed until
the peristaltic contraction has delivered the bolus into
the stomach.
CLASSIFICATION OF DYSPHAGIA
Oral and Pharyngeal (Oropharyngeal) Dysphagia
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DYSPHAGIA
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Aphagia denotes complete esophageal obstruction,
most commonly encountered in the acute setting of a
food bolus or foreign body impaction.
Odynophagia refers to painful swallowing, typically
resulting from mucosal ulceration within the
oropharynx or esophagus
Globus pharyngeus is a foreign body sensation
localized in the throat that does not interfere with
swallowing . Psychogenic. Anatomy is normal
Transfer dysphagia frequently results in nasal
regurgitation and pulmonary aspiration during
swallowing and is characteristic of opharyngeal
dysphagia.
Phagophobia (fear of swallowing)
difficulty with swallowing
refers to problems with the transit of food or liquid from
the mouth to the hypopharynx or through the
esophagus.
Severe dysphagia can compromise nutrition, cause
aspiration, and reduce quality of life.
Checked by: [MDA]
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associated with poor bolus formation and control
so that food has prolonged retention within the
oral cavity and may seep out of the mouth.
Drooling and difficulty in initiating swallowing.
Poor bolus control also may lead to premature
spillage of food into the hypopharynx with
resultant aspiration into the trachea or
regurgitation into the nasal cavity
may be due to neurologic, muscular, structural,
iatrogenic, infectious, and metabolic causes
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INTERNAL MEDICINE
OCTOBER 9, 2020
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Endocrine / metabolic disorders (Pregnancy, Uremia.
Thyroid disorders)
Toxins (Liver failure, Alcohol)
DYSPEPSIA
(GASTROESOPHAGEAL REFFLUX DISEASE)
Esophageal Dysphagia
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abnormalities of peristalsis and/or deglutitive
inhibition, potentially affecting the cervical or
thoracic esophagus.
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NAUSEA, VOMITING, AND INDIGESTION
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Nausea is the subjective feeling of a need to vomit.
Vomiting (emesis) is the oral expulsion of
gastrointestinal contents resulting from contractions of
gut and thoracoabdominal wall musculature.
Regurgitation, the effortless passage of gastric
contents into the mouth.
Rumination is the repeated regurgitation of stomach
contents, which may be rechewed and reswallowed.
Indigestion is a nonspecific term that encompasses a
variety of upper abdominal complaints including
nausea, vomiting, heartburn, regurgitation, and
dyspepsia
Dyspepsia refers to upper abdominal pain or
discomfort
DYSPEPSIA
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Types
is coordinated by the brainstem and is affected by
responses in the gut, pharynx, and thoracoabdominal
wall.
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Uninvestigated Dyspepsia- no work up of upper GI
endoscopy done
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Functional Dyspepsia- patients with dyspepsia but
negative upper GI endoscopy
DYSPEPSIA
(PEPTIC ULCER DISEASE)
CAUSES OF VOMITING:
1.
2.
Intraperitoneal
• Obstructing Disorders (Intestinal Obstruction)
• Enteric infections
• Inflammatory diseases (Cholecystitis, Pancreatitis,
Appendicitis, Hepatitis)
• Altered Sensorimotor function (Gastroesophageal
reflux disease)
Means upper abdominal discomfort.
Usually located in the epigastrium
Symptoms are: epigastric pain/burning sensation,
early satiation, postprandial fullness
Common causes
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Gastritis, gastric/duodenal ulcers
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Work up is upper GI endoscopy, test for Helicobacter
pylori infection
VOMITING
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Symptoms are caused by back flow of gastric acid and
other gastric contents into the esophagus due to
incompetent barriers at the gastroesophageal junction
Heartburn symptoms
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epigastric pain aggravated by hunger, relieved by food or
antacids
DUODENAL BULB
ENDOSCOPY:
ULCER
SEEN
ON
UPPER
GI
Extraperitoneal
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Cardiopulmonary disease (myocardial infarction)
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Labyrinthine disease (Motion sickness)
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Intracerebral
disorders
Hemorrhage, Abscess)
Psychiatric illness (Depression)
Postoperative vomiting
(Malignancy,
3. Medications / Metabolic
• Drugs (Cancer chemotherapy, antibiotics, cardiac
drugs)
[ZRC]
Checked by: [MDA]
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INTERNAL MEDICINE
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OCTOBER 9, 2020
ALARM SYMPTOMS OF DYSPEPSIA
dysphagia
Unexplained weight loss
Recurrent Vomiting
Early satiety
Occult or gross gastrointestinal bleeding
Jaundice
Palpable mass or adenopathy
Family history of GI malignancy
The presence of Alarm Symptoms suggests
malignancy!
Proper investigation should be done e.g gastroscopy or
upper endoscopy
CONSTIPATION
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persistent, difficult, infrequent, or seemingly
incomplete defecation.
Less than 3 bowel movements per week
complain of excessive straining, hard stools,
lower abdominal fullness, or a sense of
incomplete evacuation.
DIARRHEA
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passage of abnormally liquid or unformed stools at an
increased frequency
Classification :
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Acute if <2 weeks
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Persistent if 2–4 weeks, and
• Chronic if >4 weeks in duration.
[ZRC]
Checked by: [MDA]
Page 3 of 6
INTERNAL MEDICINE
OCTOBER 9, 2020
Colonoscopy
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Endoscopic procedure that is used directly to
visualiza the colon up to the ileo-cecal valve
Used to screen for colonic polyps and colon
cancer
CAUSES OF ISOLATED HYPERBILIRUBINEMIA
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JAUNDICE
due to accumulation of bilirubin in the bloodstream
causes yellow pigmentation of plasma, discoloration of
heavily perfused tissues
Can be detected when serum bililrubin level exceeds
34 to 43 mmol/L (2.0 to 2.5 mg/dl)
Indirect Hyperbilirubinemia
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Hemolytic disorders
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Ineffective erythropoiesis
(Cobalamin, folate, iron defeciencies)
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Drugs (Rifampicin)
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Inherited
conditions
(Crigler-Najjar,
syndrome)
Direct hyperbilirubinemia
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Dubin- Johnson and Rotor syndrome
HEPATOCELLULAR CONDITIONS THAT MAY PRODUCE
JAUNDICE
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CLINICAL SIGNS OF JAUNDICE:
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Gilbert’s
Scleral icteresia – a sensitive sign. Sclera is rich in
elastin
Darkening of the urine, tea-colored or beer colored
Differential dx – carotenemia: only the skin is yellowish
but not the sclera
Viral hepatitis Hepatitis A,B,C,D,E
Alcohol
Drug toxicity – isoniazid, acetaminophen
Environmental toxins
Wilson’s disease
Autoimmune hepatiis
CHOLESTATIC CONDITIONS THAT MAY PRODUCE
JAUNDICE
Intrahepatic
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Hepatitis
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Drug toxicity – erythromycin
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TB, Lymphoma, Malaria, Leptospirosis
Extrahepatic (seen on ultrasound, CT scan, MRI, ERCP)
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Malignant – Cholangiocarcinoma,
Pancreatic and Ampullary and Gallbladder CA
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Benign - Choledocholithiasis
[ZRC]
Checked by: [MDA]
Page 4 of 6
INTERNAL MEDICINE
OCTOBER 9, 2020
ASCITES
ERCP
(Endoscopic
Pancreatography)
Retrograde
Cholangio
CHOLANGIOGRAM
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Accumulation of fluid in the peritoneal cavity
Presence of fluid wave and shifting dullness on
physical examination
PARACENTESIS
A simple bedside procedure in which a needle is
inserted into the peritoneal cavity and ascitic fluid
is removed.
APPROACH TO PATIENT WITH JAUNDICE
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determine if the patient has an isolated elevation
of serum bilirubin.
is the bilirubin elevation due to an increased
unconjugated or conjugated fraction?
If the hyperbilirubinemia is accompanied by other
liver test abnormalities
is the disorder hepatocellular or cholestatic? If
cholestatic, is it intra- or extrahepatic?
ABDOMINAL SWELLING
CAUSES: 6 F’s
• Flatus
• Fat
• Fluid
• Fetus
• Feces
• Fatal growth (often a neoplasm)
[ZRC]
SAAG (SERUM-ASCITES ALBUMIN GRADIENT)
• SAAG is calculated by subtracting the ascitic
albumin from the serum albumin
• SAAG > 1.1 g/dl reflect the presence of portal
hypertension
Checked by: [MDA]
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INTERNAL MEDICINE
OCTOBER 9, 2020
HOW TO PREVENT DIGESTIVE DISEASES
Encourage high fiber diet
Avoid hepatotoxic drugs, herbal drugs, or food
supplements
• Screen for colon cancer
• Adopt a healthy lifestyle
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References:
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Digestive System PPT lecture 2020
Harrison’s Principle of Internal Medicine 20th
edition
“Eat your breakfast always”
-Zhon Pogi, 2020
[ZRC]
Checked by: [MDA]
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