GIT

Small intestinalcolonic disorders

Small intestinalcolonic disorders
Cardinal symptoms Diarrhea Constipation Weight loss Abdominal pain Lower GIT bleeding Obscured GIT bleeding Occult GIT bleeding

Small intestinalcolonic disorders

Malabsorption syndrome Protein loosing enteropathy Inflammatory bowel disease Irritable bowel syndrome

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* Diarrhea
Passage of more than 200 g of stool daily. Decrease in stool consistency and an increase stool frequency(>3 time /day) and volume Wide range of severity from mild to severe with stool urgency and incontinence

Diarrhea

Must be distinguished Pseudodiarrhea ( proctitis, IBS) Fecal incontinence Classify as Acute diarrhea Chronic diarrhea

Acute diarrhea

Acute diarrhea (<2weeks) This is extremely common Causes : Infection: 90% Short lived 10 days bacteria, their toxins, viruses or parasites
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Acute diarrhea
Pathphysiology Toxins Preformed staph toxins Enterotoxine vibrio cholera Cytotoxine E.coli Mucosal invasion salmonella Mucosal attachment giardia
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Acute diarrhea

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Acute diarrhea

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Acute diarrhea

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Acute diarrhea

Management Conservative Oral fluid IV fluid Antipyretic antispasmodic Antibiotics Empirical in moderate to severe diarrhea (ciprofloxacin plus metronidazole)


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Acute diarrhea

Acute diarrhea
Persistent diarrhea > 2weeks Giardia C. difficile E. histolytica Campylobacter Non infectious Investigation Stool examination and culture sigmoidoscopy with biopsies upper endoscopy with duodenal aspirates and biopsies

Chronic diarrhea

Duration >4 weeks Prevalence 2-7% Classified to volume (large vs. small), pathphysiology (secretory vs. osmotic) stool characteristics (watery vs. fatty vs. inflammatory) small vs. large intestinal
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Chronic diarrhea

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Chronic diarrhea

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Chronic diarrhea

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Chronic diarrhea

(secretory vs. osmotic) Large volume stool No response to fasting No abdominal pain No anion gap( <50 mosmo/l) (290 mosmol/kg)-[2 x (fecal sodium + potassium concentration)].

Chronic diarrhea

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Chronic diarrhea

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Chronic diarrhea
Evaluation of chronic diarrhea Most important steps for characterizing the type of the diarrhea are the history, examination and GSE History onset, duration, pattern stool characteristics. fever, weight loss, abdominal pain night diarrhea responding to fasting medications, surgery family history of IBD or sprue coexisting diseases as DM, thyroid
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Chronic diarrhea

Examination Malabsorption features weigt loss,anaemia, edema bone pain Inflammatory bowel disease features anaemia, mouth ulcer Abdominal mass or tenderness Mucocutaneous features erythema nodosum flushing oral ulcers
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Chronic diarrhea

Investigation CBC and ESR GSE S. electrolytes S. ca and ph S. albumin and globulin
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Chronic diarrhea Exclude medication and surgery

Stool blood and pus
Features of malabsorption Fatty foul smell stool Nutritional deficiency
Watery No abdominal pain no respond to fasting

Colonoscopy with biopsy

Small bowel image Endoscope biopsy
Osmotic gap CT abdomen Hormonal assessment
Watery Abdominal bloating Respond to fasting Increase with milk
Trial of dietary exclusion Stool PH
If normal small bowel Consider pancreatic insufficiency
CT abdomen Pancreatic function assessment

Chronic diarrhea

Treatment Fluid and electrolyte repletion Antidiarrhea Diphenoxylate loperamide Treatment of specific etiology cholestyramine for bile acid diarrhea octriotide for neuroendocrine diarrhea Clonidin for diabetic diarrhea
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Constipation

Defined as infrequent passage(< 3 bowel motions per week ) of hard stools. Patients may also complain of straining, a sensation of incomplete evacuation and abdominal discomfort. Prevalence 10-20%
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Constipation

Gastrointestinal disorders Dietary Lack of fiber and/or fluid intake Motility Irritable bowel syndrome Chronic intestinal pseudo-obstruction (low-transit constipation) Hirschsprung's disease

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Constipation

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Constipation
Non-gastrointestinal disorders Drugs Opiates Anticholinergics Calcium antagonists Iron supplements Aluminium-containing antacids Neurological Multiple sclerosis Spinal cord lesions Cerebrovascular accidents Parkinsonism
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Constipation

Metabolic/endocrine Diabetes mellitus Hypercalcaemia Hypothyroidism Pregnancy Others Any serious illness with immobility, especially in the elderly Depression
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Constipation

Approach to the Patient History Frequency (e.g., fewer than three bowel movements per week) consistency (lumpy/hard) excessive straining, prolonged defecation time digitate the anorectum diet and medication history
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Constipation

The onset, duration neonatal onset Hirschsprung‘sRecent change in bowel activity colonic carcinoma. Associated symptoms such as rectal bleeding, pain and weight loss is important * add footer here (go to view menu and choose header)
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Constipation

Physical examination Search for general medical disorders Signs of intestinal obstruction Abdominal and rectal examination Investigate basic tests: serum calcium, potassium, and thyroid hormone levels. Barium enema less costly identifies colonic dilatation
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Constipation
Sigmoidoscopy plus barium enema or colonoscopy alone weight loss rectal bleeding Anemia patients >40 years (recent)
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Constipation

Tests physiologic function of the colon and pelvic floor Measurement of Colonic Transit Anorectal and Pelvic Floor Tests Anorectal manometry(balloon expelsion and sphinicter pressure) Defecography
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Constipation

Treatment Trial of dietary fiber chronic constipation no alarm features normal basic tests If No response consider evaluation of the colon by colonoscopy and Barium study If No pathology consider potent laxatives osmotic, and stimulant laxatives

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Constipation

Disabling symptoms specialist referral for investigation of possible dysmotility and pschycolgical assessment. According to the finding in the physiological test: slow-transit constipation 1. long time trial of potent laxative osmotic prokinetic stimulant

Constipation

2. Surgery Laparoscopic colectomy with ileorectostomy Failure medical therapy Unassociated general slow-transit constipation Unassociated obstructed defecation Evacuation disorder pelvic floor retraining (biofeedback and muscle relaxation)


Constipation

Weight loss

Definition loss of more than 3 kg(5% body WT) over 6 months is significant. Is common problem What is the significance of WT loss Harbor significant disease decreased performance status Increase morbidity and mortality impaired responses to chemotherapy

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Weight loss

Causes of the WT loss 'physiological' dieting exercise old age Pathological systemic disease gastrointestinal diseases advanced disease of many organ systems psychiatric illness
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Weight loss
Some easily overlooked causes of unexplained weight loss Chronic pain or sleep deprivation Psychosocial Depression/anxiety Existing conditions (severe chronic obstructive pulmonary disease, cardiac failure)
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Weight loss

Some easily overlooked causes of unexplained weight loss Diabetes mellitus/hyperthyroidism Occult malignancy (e.g. proximal colon, renal, lymphoma) Anorexia nervosa in atypical groups, e.g. young men Rare endocrine disorders, e.g. Addison's disease, panhypopituitarism
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Weight loss
Approach to the Patient Weight Loss Confirm weight loss History-taking Physical examination Laboratory testing
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Weight loss

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Weight loss

Additional testing HIV test Upper and/or lower gastrointestinal endoscopies Abdominal CT scan or MRI Chest CT scan
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Abdominal pain

Types of abdominal pain Visceral. Parietal. Referred pain. Psychogenic.
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Abdominal pain

Causes of acute abdominal pain Abdominal (GIT ) Inflammation Appendicitis Diverticulitis Cholecystitis Pelvic inflammatory disease Pancreatitis Pyelonephritis Gastroenteritis
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Abdominal pain
Perforation/rupture Peptic ulcer Diverticular disease Ovarian cyst Aortic aneurysm Obstruction Intestinal obstruction Biliary colic Ureteric colic Acute bowel ischemia

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Abdominal pain

Exrtaintestinal Cardiac Myocardial ischemia / infarction Thoracic Pneumonia pneumothorax Esophagitis

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Abdominal pain

Locomotor Vertebral compression Abdominal muscle strain Metabolic/endocrine Diabetes mellitus Addison's disease Acute intermittent porphyria Hypercalcaemia
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Abdominal pain

Haematological Sickle-cell disease Haemolytic disorders Neurological Spinal cord lesions Radiculopathy Tabes dorsalis
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Abdominal pain
Toxins Lead Alcohol Miscellaneous Familial mediterranean fever Psychiatric disorders Muscle contusion

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Abdominal pain
Causes of chronic abdominal pain Chronic intermittent Mechanical Intestinal obstruction Gallstones Sod

Abdominal pain

Inflammatory IBD PUD Recurrent pancreatitis FMF Endometriosis Chronic mesentric ischemia

Abdominal pain

Metabolic Porphyria Neurological Radiculopathy Functional Dyspepsia IBD

Abdominal pain

Chronic constant pain Organmegaly Malignancy Chronic pancreatitis Abscess Psychiatric

Abdominal pain

How to assess chronic abdominal pain Duration Site and radiation Severity Precipitating and relieving factors Nature (colicky, constant dull) Pattern (intermittent or continuous) Associated features (vomiting, dyspepsia, altered bowel habit)


Abdominal pain
Investigations Routine lab IXs US OGD and colonoscopy CT abdomen Angiography

Lower gastrointestinal bleeding

Bleeding below the ligament of treitz This may be due to bleeding from colon anorectal area small bowel classified: Acute bleeding Chronic or sub acute bleeding

Lower gastrointestinal bleeding

Manifestation profuse red blood Hematochezia maroon stool malaena

Lower gastrointestinal bleeding

Acute bleeding Diverticular disease Angiodysplasia Ischaemic colitis Colitis ( inflammatory, infectious) Neoplasia CRC and polyp Small intestinal lesion vascular or tumor Meckel's diverticulum Rare rectal varices

Lower gastrointestinal bleeding

Chronic/subacute bleeding Anal disease, e.g. fissure, hemorrhoids Inflammatory bowel disease Carcinoma Large polyps Angiodysplasia Solitary rectal ulcer

Lower gastrointestinal bleeding

managment Resuscitation Blood transfusion Admission to ICU Searching the cause Treatment Endoscopic Angiographic surgical

Acute lower GIT bleeding

Hemodynamic stability
Hemodynamic instability
colonoscopy
Upper endoscopy
colonoscopy
Bleeding stopped Mild bleeding
Severe continued bleeding
Enteroscopy
Angiography RBC scan
Radiological study vediocapsule
enteroscopy
Inraoperativendoscopy
Angiography RBC scan

ENDOSCOPIC TREATMENT

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Colonic diverticula

colonic angiodysplasia

Ulcerative colitis

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Colonic carcinoma

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Colonic polyp

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Internal piles
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Obscure gastrointestinal bleeding

Persistent or recurrent bleeding for which no source has been identified by routine endoscopic OGD and colonoscopy Manifestation melena hematochezia red maroon stool Main causes Gastric vascular lesion (dieulafoy) vascular abnormalities of the SI Tumors of the SI Meckel's diverticulum Aortoentric fistula

Obscure gastrointestinal bleeding

Investigations Push enteroscopy Video capsule endoscopy enteroscopy Tc-labeled red blood cell scintigraphy Angiography Meckel's diverticuloscan intraoperative endoscopy

Thank you

Occult gastrointestinal bleeding
bleeding present in the stool but cannot be seen by the naked eye Manifestation iron deficiency anaemia causes Any cause of gastrointestinal bleeding most important is colorectal cancer

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Occult gastrointestinal bleeding

Investigations stool fecal occult blood (FOB) test colonoscopy. upper endoscopy radiological study ( barium) enteroscopy video capsule endoscopy

Vediocapsule

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Double balloon Enteroscopy

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Occult gastrointestinal bleeding

Jejunum mass
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Dieulafoy lesion

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