Cycle II, Module C, Course 6 (GIT and abdominal problems)
Prof. MUDr. Jiří Horák
Seminar 1. Introduction. Examination procedures in GIT and abdominal
problems
Introduction
- clinical and epidemiologic significance of gastrointestinal and abdominal
problems
- history
- typical gastrointestinal and abdominal symptomes, signs and syndromes
- physical examination
- auxilliary examinations
Gastrointestinal symptoms and signs
- abdominal pain & colic
- weight loss
- anorexia
- nausea & vomiting
- heartburn = retrosternal burning pain
- dysphagia & odynophagia
- diarrhoea
- constipation
- flatulence
- biliary dyspepsia and colic
- disorders of hematopoiesis and hemocoagulation, gastrointestinal bleeding
- jaundice
- hepatic encephalopathy
- abdominal swelling, water retention and ascites
- pruritus (itching)
- hepatorenal syndrome (functional renal failure)
- portal hypertension and esophageal varices bleeding
Genitourinary symptoms and signs
- change in appearance of the urine
- urinary obstruction
- anuria (<50 ml urine daily), oliguria, polyuria, nocturia, polakisuria
- menstrual problems
- lumbar pain
- renal colic
Laboratory findings
a) nonspecific markers of inflammation or malignant growth
- erythrocyte sedimentation rate
- C-reactive protein
- protein electrophoresis
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Cycle II, Module C, Course 6 (GIT and abdominal problems)
Prof. MUDr. Jiří Horák
- blood count
- serum complement concentration (decreased in arthritis, vasculitis, nephritis)
- other acute-phase proteins (fibrinogen, ferritin, haptoglobin, coeruloplasmin,
alpha-1 antitrypsin etc.) are not used for inflammatory activity assessment
b) functional examination
- gastric chemistry
- pancreozymin-secretin test
- bentiromide test
- chromoexcretory tests of liver function (bromphtalein, indocyanine green,
rose bengal, IDA-derivatives)
- metabolic tests of liver function: galactose test, antipyrine test
- pH-metry
- stool examination for fat and residues
- xylose test
- beta-carotene
- hemocoagulation
c) tests for GIT bleeding
- benzidine test
- Hemoccult
d) protein exudation into the GIT
- radioactive chromalbumin test
e) the so-called liver function tests
- bilirubin
- ALT, AST
- GMT, ALP
- other tests useful in diagnosis and monitoring of liver disease:
blood count, serum protein, hemocoagulation tests, iron, creatinine, glucose,
triglycerides, cholesterol, ammonia, bile acids
f) pancreas examination
- amylase
- lipase
g) urine chemistry
- bilirubin
- urobilinogen
- protein
- glucose
- keton bodies
h) antibodies and autoantibodies (cf. table Antibodies and autoantibodies in
autoimmune hepatitis)
- ANA
- ASMA
- AMA - typically in primary biliry cirrhosis
- ANCA (p, c)
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Cycle II, Module C, Course 6 (GIT and abdominal problems)
Prof. MUDr. Jiří Horák
- against thyroid tissue
- against gastric mucosa
- against intrinsic factor
- LKM antibodies etc.
i) serology and molecular biology of viral hepatitis
- hepatitis A
- hepatitis B
- hepatitis C
- hepatitis D
- hepatitis E
- hepatitis G
- TTV-hepatitis
j) tests for Helicobacter pylori
- histology
- antibodies
- urease test
- breath tests
k) microbiological examination
- stools
- ascites
- bile
- urine
- other
l) serological tests in microbiological diagnostics
m) tests in metabolic diseases
- hepatic porphyrias
- Wilson's disease
- genetic hemochromatosis
- cystic fibrosis
- alpha-1 antitrypsin deficiency
n) tumour markers
- alpha-fetoprotein - hepatocellular carcinoma
- carcinoembryonic antigen - colorectal carcinoma
- Ca 19-9 - pancreatic carcinoma
- Ca 125 - gynecological carcinomas, carcinoma of the liver, pancreas and
lungs
- gastrin - gastrinoma
- C-peptide – insulinoma
Imaging methods, endoscopy and biopsy
- abdominal sonography
- endosonography
- X-ray of the esophagus
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Cycle II, Module C, Course 6 (GIT and abdominal problems)
Prof. MUDr. Jiří Horák
-
plain abdominal X-ray
X-ray of the stomach and duodenum
gastrointestinal transit
enteroclysis
irrigography
ERCP
PTC
CT
NMR
arteriography
cavography
lymphography
splenoportography
peroral cholecystography and intravenous cholangiography
static hepatic scintigraphy
cholescintigraphy
esophagogastroduodenoscopy
colonoscopy
rectosigmoidoscopy
laparoscopy
blind and guided biopsy of the abdominal organs
Pressure measurements
- in the GIT (esophagus, sphincter of Oddi, rectum)
- in the portal vein (directly, wedged hepatic vein pressure)
Histologic and cytologic examination
- esophageal mucosa
- gastric mucosa
- duodenal mucosa
- jejunal and ileal mucosa
- colonic mucosa
- liver and biliary tree
- pancreas
- ascites
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Cycle II, Module C, Course 6 (GIT and abdominal problems)
Prof. MUDr. Jiří Horák
Appendix
INDICATION AND INTERPRETATION OF VIRAL HEPATITIS MARKER
EXAMINATION
Hepatitis A
- anti-HAV IgM
- anti-HAV IgG
Hepatitis B
- HBsAg
- HBeAg
- anti-HBc IgM
- anti-HBc IgG
- anti-HBc total
- HBV DNA
- quantitative viremia
- anti-HBs
- anti-HBe
- interpretation of the results cf the table
Hepatitis C
- anti-HCV
- anti-HCV IgM
- RIBA (recombinant immunoblot assay)
- HCV RNA
- genotype
- quantitative viremia
Hepatitis D
- anti-HDV
- anti-HDV IgM
- HDV RNA
- coinfection HBV + HDV: anti-HBc IgM + anti-HDV
- HDV superinfection on standing HBV infection: anti-HBc IgG + anti-HDV
Hepatitis E
- anti-HEV total
- anti-HEV IgM
- anti-HEV IgG
Hepatitis G
- HGV RNA
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Cycle II, Module C, Course 6 (GIT and abdominal problems)
Prof. MUDr. Jiří Horák
TTV-hepatitis (Transfusion-transmitted virus)
- TTV DNA
Differential diagnosis of viral hepatitis
- acute viral hepatitis: EB-virus, herpes simplex virus, cytomegalovirus,
coxsackie virus
- autoimmune hepatitis
- toxic hepatitis (toxins, drugs, alcohol)
- primary biliary cirrhosis
- primary sclerosing cholangitis
- Wilson's disease
- hepatic porphyrias
- biliary tree obstruction
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Cycle II, Module C, Course 6 (GIT and abdominal problems)
Prof. MUDr. Jiří Horák
Antibodies in autoimmune hepatitis
antibody
antigen
AIH type I AIH type II AIH t. III
ANA
nuclear membrane
+
+
ASMA
actin
+
+
AAA
actin
+
ANCA
actin
+
LKM1
cytochrome P450 IID6
+
LKM2
cytochrome P450 IIC9
+
LKM3
UDP-glucuronyltransferase
+
AMA
LCA
SLA
pyruvate dehydrogenase E2
dsDNA
DNA
+
liver cytosol antigen
cytokeratin 8 and 18
+
+
+
ANA - antinuclear antibody
ASMA - anti-smooth muscle antibody
AAA – antiactin antibody
ANCA – antineutrophil cytoplasmic antibody
LKM - liver-kidney microsomal antibody
AMA - antimitochondrial antibody
SLA - soluble liver antigen
ds-DNA – double-stranded DNA
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Cycle II, Module C, Course 6 (GIT and abdominal problems)
Prof. MUDr. Jiří Horák
Typical laboratory findings in hepatitis B
anti-HBs
HBeAg
+
-
+
-
+
+
+
acute hepatitis B
+
-
+
-
+
+
+
+
-
-
+
-
+
-
+
-
-
+
+
+
+
+
-
-
+
-
+
-
-
+
-
+
-
+
-
chronic hepatitis B, active replication, highly
infectious
chronic hepatitis B, low replication, low
infectivity
infection by e-minus variant of the virus,
active replication, highly infectious
HBsAg carrier or chronic hepatitis B with
low replication
healed hepatitis B
-
+
-
-
-
-
-
-
-
-
-
-
+
-
HBsAg
anti-HBe anti-HBc anti-HBc HBV DNA
IgM
total
Interpretation
condition after vaccination or healed
hepatitis B
healed hepatitis B