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 ✔✔ THE GASTROINTESTINAL SYSTEM Anatomy and Physiology GI system includes the alimentary tract, liver, biliary system, pancreas and spleen. The alimentary tract extends from the mouth to the anus and includes the oesophagus, stomach, small intestine or smal...

 ✔✔ THE GASTROINTESTINAL SYSTEM Anatomy and Physiology GI system includes the alimentary tract, liver, biliary system, pancreas and spleen. The alimentary tract extends from the mouth to the anus and includes the oesophagus, stomach, small intestine or small bowel (duodenum, jejunum and ileum), colon (large intestine or large bowel) and rectum abdominal surface can be divided into nine regions left m clavicular midcavicular L L5 mid clavicular Line - History Mouth symptoms - (s infections Halitosis → Bad breath due to gum, dental or pharyngeal infection & & is gau/dental/pharynged & Xerostomia → dry mouth Dysgeusia → altered taste sensation > - &is I Cacogeusia → foul taste in the mouth s's Is · 27 Xerstomia =13. Case : 40 YO female, dry mouth, dry eyes routh Dx? Sjogren syndrome dry Syndrous Sjogrens argeyes ~> - Cimmur]  Anorexia and weight loss Anorexia is a loss of appetite and/or a lack of interest in food. Significant: 10% in 6 months => + unintentional 5% in 3 months 2% in 1 month - - Case : 70 year old male, significant weight loss Dx ? Think of malignancy Energy requirements average 2500 kcal/day for males and 2000 kcal/day for females net calorie deficit of 1000 kcal/day results in weight loss of approximately 1 kg/week (7000 kcal y 1 kg of fat) Greater weight loss during the initial stages of energy restriction arises from salt and water loss and depletion of hepatic glycogen stores, not from fat loss. Rapid weight loss over days suggests loss of body fluid as a result of vomiting, diarrhoea or diuretics (1 L of water = 1 kg) Weight loss or malnutrition Reduced energy intake Increased energy expenditure reduced Diet ↑ apiteven fever eg infection loss of appetite (eg , malignancy) malabsorption - expande thyrotoxicosis malignancy J cliac J malnutrition e is · feciliat ut loss Case : 13 year old female, wt loss , IDA , multivitamin deficiency, herpetiformrash on the skin IDA def V setiformas Dx? Celiac disease - · vit mett her  - - 6) Ei Pain baluker Mouth pain je age Herpes -X Oral ulcer Herpes Tongue Pain Labialis C or Ddx is R labial B deficiencies, including iron, folate, vitamin B12 or C Vitamine lichen planus on folate , chemotherapy , aphthous ulcers (due to stress) including i - - IBD ( crohn’s) Deficiencies , coeliac disease · lichen planus · chemo trai Heartburn and reflux Retrosternal burning sensation - u Ddx GERD is - To differentiate heartburn from cardiac chest pain, ask about associated features: character of pain: burning dest radiation: upward GRED precipitating factors: lying flat or bending forward associated symptoms: - burning waterbrash (sudden appearance of fluid in the mouth due to reflex regurgitation the taste of acid appearing in the mouth due to reflux -upwards flat laying - Odynophagia dor withlying pain from swallowing, bring often precipitated by drinking hot liquids. It can be present with or without dysphagia and may indicate : oesophageal ulceration oesophagitis GERD oesophageal M - candidiasis  Dyspepsia Dyspepsia is pain or discomfort centred in the upper abdomen. In contrast, ‘indigestion’ is a term commonly used by patients for ill-defined symptoms from the upper gastrointestinal tract - Clusters of symptoms are used to classify dyspepsia: reflux-like dyspepsia (heartburn-predominant dyspepsia) ulcer-like dyspepsia (epigastric pain relieved by food or antacids) dysmotility-like dyspepsia (nausea, belching, bloating and premature fullness (early satiety). Jeserial pain & Distension Abdominal pain & spasm S SOCRATES Straction Case : 22 yearold female, acute abdominal pain , around The umbilicus => After 4 hours * , it shifted to RIF Dx? Appendicitis > - Pain stated first due to Distension >> visceral pain (poorly localized) Then irritation of parietal pertoneum >> somatic pain (well localized) 7. after 24 hours of appendicitis >> appendiceal rupture = perforated appendix >> generalized peritonitis : Guarding and Rigidity with rebound tenderness - Site Visceral abdominal pain from distension of hollow organs, mesenteric traction or excessive smooth-muscle contraction is- deep and poorly localised in the midline , The pain is conducted via sympathetic splanchnic nerves. - 2nd partenum o - until 2/3rds transverse 6 Colon -  Pain arising from foregut structures (stomach, pancreas, liver and biliary system) is localised above the umbilicus. Central abdominal pain arises from midgut structures, such as the small bowel and appendix. Lower abdominal pain arises from hindgut structures, such as the colon. Inflammation may cause localised pain: for example, left iliac fossa pain due to diverticular disease of the sigmoid colon. Pain from an unpaired structure, such as the pancreas, is midline and radiates through to the back. Pain from paired structures, such as renal colic, is felt on, and radiates to, the affected side Somatic pain from the parietal peritoneum and abdominal wall is lateralised and localised to the inflamed area. It is conducted via intercostal nerves. Abdominal pain Testicular pregnancy complications Torsion (Ruptured ectopic pregnancy) ovarian torsion PID Ovarian cyst rupture Case : 40 year old male, abdominal pain epigastric, Gradual, burning/ Gnawing , Relived by food and by antacids - Exacerbated with alcohol and NSAIDs - Dx? Peptic ulcer disease - PUD Gastric ulcer Duodenal ulcer ( most common ) Increase by food Decrease by food -  Onset an Sudden onset of severe abdominal pain, rapidly progressing to become generalised and constant, suggests a hollow viscus perforation (usually due to peptic ulceration, diverticular disease or colorectal cancer), a ruptured abdominal aortic aneurysm or mesenteric infarction. Torsion of the caecum or sigmoid colon (volvulus) presents with sudden abdominal pain OxBillian ↳ associated with acute intestinal obstruction. A whic = Case : 45 year-old female with right upper quadrant pain , Recurrent episodes , after fat rich nad meals Chr The pain lasts for 3 hours and radiates to Shoulder & tip of scapula Dx? Biliary colic Case : 48 year-old female with Acute RUQ pain , radiates to Shoulder and tip of scapula Lasting for 24 hours > 24hr Dx? Cholecystis Crim pain Case : 50 YO male , alcoholic , with high triglycerides and high Ca levels presented with acute Epigastric pain radiates to back , Relived by leaning forward Dx? Acute pancreatitis Case ; 35 YO female , right loin pain , radiating to the groin , reaching the right labia majora Pain was severe and following a period of Dehydration Dx? Renal colic Character Colicky pain lasts for a short time (seconds or minutes), eases off and then returns. It arises from hollow structures, as in small or large bowel obstruction, or the uterus during labour. Dull, constant, vague and poorly localised pain is more typical of an inflammatory process or infection, such as pelvic inflammatory disease, appendicitis or diverticulitis Biliary and renal ‘colic’ are misnamed, as the pain is rarely colicky; pain rapidly increases to a peak and - persists over several hours before gradually resolving. F  tipscula Radiation Pain radiating from the right hypochondrium to the shoulder or interscapular region → diaphragmatic irritation (eg acute cholecystitis ) O Pain radiating from the loin to the groin and - genitalia is typical of renal colic. Central upper abdominal pain radiating through to the back, partially relieved by sitting forward, suggests pancreatitis. Central abdominal pain that later shifts into the right iliac fossa occurs in acute appendicitis. The combination of severe back and abdominal pain may indicate a ruptured or dissecting abdominal aortic aneurysm. Case : 60 YO male, HTN , severe acute abdominal pain , on physical examination he had pulsatile Mass and low Blood pressure & Asymmetric pulses Dx? Ruptured AAA Case: 52 yearold female , vomiting , constipation , abdominal pain , abdominal distention Had a previous open cholecystectomy Dx? Intestinal obstruction Case : 70 YO male with A fib , HTN , acute abdominal pain , bloody diarrhea , Nausea , - vomiting On physical exam ; absent bowel sounds , guarding , rigidity , rebound tenderness ( signs of peritonitis) , Dx? Mesenteric ischemia Associated symptoms Non specific symptoms > Anorexia, nausea and vomiting are common may be absent, even in advanced intra-abdominal disease. altered bowel habit > irritable bowel syndrome , diverticular disease or colorectal cancer - breathlessness or palpitation> non-alimentary causes. > - Hypotension and tachycardia > sepsis or bleeding  - J GT hystation NO n S Pneumann DM - frint IV Timing silent interval first 1–2 hours after perforation may occur when abdominal pain resolves transiently. The initial chemical peritonitis may subside before bacterial peritonitis becomes established. Example : acute appendicitis, pain is initially periumbilical (visceral pain) and moves to the right iliac fossa (somatic pain) when localised inflammation of the parietal peritoneum becomes established. If the appendix ruptures, generalised peritonitis may develop. Occasionally, a localised appendix abscess develops, with a palpable mass and localised pain in the right iliac fossa A change in the pattern of symptoms > wrong diagnosis or complications happened In acute small bowel obstruction, a change from typical intestinal colic to persistent pain with abdominal tenderness suggests intestinal ischemia. - Abdominal pain persisting for hours or days suggests an inflammatory disorder, such as acute - appendicitis, cholecystitis or diverticulitis.  pain Y / colicky Restless Nausea someting soilds oesophageal dysmotility Mouth ulcers Wt loss UMN Tonsillitis LMN middle age no reflux symptoms worse for solids short history & improve by liquids and sitting upright oesophageal choking, Cancer malignant spluttering and Eg, achalasia fluid Progressive regurgitating Solid then liquid Longstanding from the nose. no wt loss heartburn benign peptic stricture Ask about: onset: recent or longstanding nature: intermittent or progressive difficulty swallowing solids, liquids or both the level where food is felt to stick If dysphagia is experienced high in the neck, any regurgitation or reflux of food or fluid consider tumours of the pharynx or larynx or any associated pain (odynophagia) or heartburn extrinsic compression from a mass lesion such as a any recent weight loss. thyroid goitre. past history of food bolus obstruction dysphagia is not early satiety : the inability to complete a full meal because of premature fullness, and is not with globus : feeling of a lump in the throat. Eosinophilic oesophagitis is the most common cause of food bolus obstruction and should be considered in younger patients with dysphagia; it is associated with atopy and food allergy. pharyngeal pouch food stick causing Eg, achalasia halitosis lead to dilatation undigested food above the sphincter from previous days lead to recurrent chest infections due to chronic silent aspiration.  " ☕ Case : 70 Yo male , dysphagia , started with solids and now it’s solids and liquids , associated with wight loss Ddx ? Esophageal cancer Fatiguability Case : 40 YO male long standing GERD Presented with progressive dysphagia To solids , Ddx ? Benign peptic stricture Nausea and vomiting Nausea is the sensation of feeling sick. Vomiting is the expulsion of gastric contents via the mouth. ABC Both are associated with pallor, sweating and hyperventilation. Amount → if large amount then vomiting is the main symptom ( gastroenteritis) Blood → coffee ground emesis → bleeding PUD peptic wher disease * Color Consistency → thin or thick fluids or peaces of food or blood clots Content : bile stained (green )→ intestinal obstruction distal to& = 2nd part of duodenum OR feculent (brown)→ Distal small bowel obstruction or colon obstruction - Dyspepsia causes nausea without vomiting. Peptic ulcers → painless vomiting unless they are complicated by pyloric stenosis Pyloric stenosis → projectile vomiting of large volumes of gastric content that is not bile stained. Severe vomiting without significant pain → gastric outlet or proximal small bowel obstruction. - peritonitis → small in volume but persistent. The more distal the level of intestinal obstruction, the more marked the accompanying abdominal distension - → most common cause is adhesions ‫ﺣﺪا ﺻﻐﯿﺮ ﺑﺎﻟﻌﻤﺮ ﻋﻤﻞ ﻋﻤﻠﯿﺔ‬ Vomiting is common in gastroenteritis, cholecystitis, pancreatitis and hepatitis. Severe pain may precipitate vomiting → renal or biliary colic or myocardial infarction. → small amounts Anorexia nervosa Bulimia nervosa 19 YO female Wt neutral Both have undisclosed Vomiting Or increased self induced vomiting Wt loss - -Amenorrhea  Common bile duct opens in 2nd part of duodenum non-gastrointestinal causes of nausea and vomiting include: drugs ( opioids, theophyllines, digoxin, cytotoxic agents, J antidepressants or alcohol) pregnancy diabetic ketoacidosis DKA renal or liver failure hypercalcaemia Addison’s disease raised intracranial pressure (meningitis, brain tumour) → vomiting without nausea small amounts vestibular disorders (labyrinthitis and Ménière’s disease). Wind and flatulence & Belching due to air swallowing (aerophagy) and has no medical significance. - It may indicate anxiety but sometimes occurs in an attempt to relieve abdominal pain or discomfort and accompanies GORD. - & Excessive Flatus mixture of gases derived from swallowed air and colonic bacterial fermentation of poorly absorbed carbohydrates. Normally, 200–2000 mL of flatus is passed each day. Excessive flatus → lactase deficiency and intestinal malabsorption. & Borborygmi →audible bowel sounds result from the movement of fluid and gas along the bowel. Loud borborygmi, particularly if associated with colicky discomfort, suggest small bowel obstruction or dysmotility. small bre Abdominal distention ~ ~ v ~ ~ ~ V  ✔ ✔ ✔ ✔ ✔ SAAG = (serum albumin) − (albumin level of ascitic fluid) SAAG >1.1 think of portal HTN SAAG < 1.1 non portal HTN Change in bowel habits Diarrhea : more than 3 times daily or frequent passage of loose stool - Clarify : frequency vs. consistency E 1. Steatorrhea : fat 7g/day Greasy, pale, bulky, float, difficult to flush, foul smelling ddx ? Fat malabsorption Celiac disease Cystic fibrosis Chronic pancreatitis v - - 2. Bloody : IBD acute mesenteric ischemia Infective gastroenteritis → eg salmonella , shigella , enterohemorrhagic E-coli Low-volume diarrhea is associated with the irritable bowel syndrome. pain , dyspepsia , bloating romecriteria of diagnosis of IBS ( not required ) High-volume diarrhea (>1 liter per day) occurs when stool water content is increased secretory, due to intestinal inflammation, as in infection or inflammatory bowel disease →doesn’t stop with fasting , eg cholera, IBD osmotic, due to malabsorption, drugs (as in laxative abuse) or motility disorders (autonomic neuropathy, particularly in diabetes) → stops with fasting The most common cause of acute diarrhoea is infective gastroenteritis due to norovirus, Salmonella species or Clostridium difficile. if > 4 weeks → chronic ( giardia , amebic ) Ask about Onset : Acute, Chronic, intermittent Stool: frequency, volume, color, consistency (watery, unformed, semisolid), Content (red blood,mucus,pus) Associated features: urgency, fecal incontinence, tenesmus, abdominal pain, vomiting, sleep disturbance. Recent travel: traveller diarrhea, TB Case : 50 YO male, wt loss , abdominal pain, steatorrhea , alcoholic , Ddx? Chronic pancreatitis Case : Change in bowel habits in patient over 50 YO can be Colon cancer → rt sided ca Case : patient takes Abx then had bloody diarrhea Ddx ? Think of clostridium difficile Constipation infrequent passage of hard stools , less than once in 3 days Ask about Bristol scale Obstipation: Absolute constipation with no gas or bowel movements, suggests intestinal obstruction Tenesmus: feeling of incomplete evacuation, suggests rectal inflammation or cancer(the sensation of needing to defecate although the rectum is empty) Anesmus : difficulty to empty the rectum despite straining due to paradoxical contraction of puborectalis muscle Causes : Lack of fibers Immobility IBS Drugs eg, opioid and iron Hypothyroidism Intestinal obstruction ( colon cancer)  ✔ ✔ Bleeding Haematemesis vomiting blood, which can be fresh and red, or when it is dark brown in colour and resembles coffee grounds. Ask about : Color , fresh , coffee ground Amount Onset Most common cause is PUD Previous hx Alocohol, nsaid, steroids Melaena the passage of tarry, shiny black stools with a characteristic odor and results from upper gastrointestinal bleeding. Distinguish this from the matt black stools associated with oral iron or bismuth therapy. ① Fresh rectal bleeding (heamatocazia) indicates a disorder in the anal canal, rectum or colon. Blood may be mixed with stool, coat the surface of otherwise normal stool, or be seen on the toilet paper or in the pan. During severe upper gastrointestinal bleeding, blood may pass through the intestine unaltered, causing fresh rectal bleeding. > - painless 5 > - painful -  ✔ ✔ ✔ Jaundice Jaundice is a yellowish discoloration of the skin, sclerae and mucous membranes due to hyperbilirubinaemia. Most clinicians will recognize jaundice when bilirubin levels exceed 3 mg\dl · I Prehepatic jaundice : hemolysis Direct VS. Indirect hyperbiliirubenemia Indirect : 50% of congugated(D) billrubin Posthepatic / cholestatic jaundice Groin swellings and lumps Past history History of a similar problem may suggest the Hernia diagnosis: for example, bleeding peptic ulcer or Lymph nodes inflammatory bowel disease. Skin and subcutaneous Lumps Primary biliary cirrhosis and autoimmune Saphenavarix hepatitis are associated with thyroid disease. Hydroceele (NAFLD) is associated with diabetes and Undescended testis 1obesity. - Yonachteresse Femoral aneurysm Psoasabscess Drug history Family history Inflammatory bowel disease is more common in patients with a family history of either Crohn’s disease or ulcerative colitis. Colorectal cancer in a first-degree relative increases the risk of colorectal cancer and polyps. Peptic ulcer disease is familial but this may clindamycin be due to environmental factors, e.g. transmission of Helicobacter pylori infection. Gilbert’s syndrome is an autosomal dominant condition. recurrent jaundice Haemochromatosis and Wilson’s disease are autosomal recessive disorders. Autoimmune diseases, particularly thyroid disease, are common in relatives of those with primary biliary cirrhosis and autoimmune hepatitis. A family history of diabetes is frequently seen in the context of NAFLD Social history Dietary history and food intolerance Risk factors for liver disease alcohol consumption IV drug abuse Smoking risk of oesophageal cancer, Tattoos colorectal cancer, Crohn’s disease Foreign travel and peptic ulcer, while patients with Blood transfusion ulcerative colitis are less likely to Homosexuality smoke smoking is protective to UC Multiple sexual partners stress Irritable bowel syndrome and History of hepatitis B or C dyspepsia Foreign travel