4 th year Gastroenterology Lectures Abdominal pain Jaundice GI bleeding

1. 4th year Gastroenterology LecturesAbdominal painJaundiceGI bleeding Yasir M Khayyat MBcHB,FRCPC,FACP Assistant Professor of Medicine

2. Objectives of approach to abdominal pain • Recognize the appropriate analysis of abdominal pain and consistently apply it. • Understand the differential diagnosis of abdominal pain by location and patient setting. • Apply the necessary investigations pertinent to the presenting abdominal pain

3. Approach to abdominal pain

4. Clinical Assessment

6. Basic principles: • Introduce yourself • Know what system or disease type you are evaluating • Write down • Be brief and focused

7. Abdominal Pain Analysis

8. Differential Diagnosis of Abdominal Pain by site Think also of non Abdominal organs Heart Lungs Spine Metabolic Aorta

9. Approach to Jaundice

10. Objectives of the approach to Jaundice • Recognize the appropriate analysis of clinical jaundice and consistently apply it. • Perform the physical examination necessary to elicit the diagnosis. • Prioritize the common causes of jaundice and apply it in investigations.

11. Jaundice : definition • Yellow discoloration of the tissues caused by retention of bilirubin.( skin,sclera,mucosa) • Detected when serum bilirubin exceed 2.5-3 mg/100 ml. • Direct bilirubin undergoes postproduction processing in the liver ,this helps in differentiating between • Pre-hepatic • Hepatic • Post-hepatic

13. History : • Age • Onset • Duration :short hx of malaise,anorexia and myalgia= viral • Long hx weight loss ,anorexia = carcinoma • Pregnant females • Noticed: by the Patient/Relative • Progression • Associated Symptoms: fever: cholangitis Abdominal pain: gall stones, pancreatic carcinoma viral prodrome

14. Past medical history: Hem-Liver,contact with febrile patient • Past surgical history: including post operative phase • Travel history • Previous Drugs/Illict drugs,Alcohol • Previous GI Imaging or Lab works • Family history ( such as hemolytis disorders,wilson’s disease,Gilbert’s disease,alpha 1 antitrypsin defeciency )

15. Physical Examination

16. Physical examination: • General appearance : Wasted/Weak • Vital Signs • Hands : Yellow, Clubbing, vasculitic lesions,SBE • Face : Malnutrition,Icterus,Fetor hepaticus • Trunk : signs of CLD • Abdomen : Ascites,signs of CLD,Splenomegaly,masses • LL : LL edema

17. Isolated Disorders of Bilirubin MetabolismCongugatedhyperbilirubinemiaUncongugatedhyperbilirubinemiaLiver DiseaseAcute hepatocellular dysfunction Chronic hepatocellular dysfunction Hepatic disorders with prominent cholestasis Jaundice in pregnancy Jaundice in the postoperative periodObstruction of the Bile DuctsCholedocholithiasis Diseases of the bile ducts Extrinsic compression of the bile ducts

18. Most Common causes of Jaundice • Hemolysis • Viral hepatitis • Alcoholic liver disease • Drugs • Bile duct stones • Pancreatic carcinoma • Liver metastasis

20. Jaundice Work up • CBC : hemolysis ( Hb , Bilirubin ,LDH • LFT : AlK P, GGT • Hepatitis Virus serology : HBV ( HBsAg , HBeAg ) – HCV (HCV Ab ) – HAV ( IgM,IgG ) • PBC ( AMA , IgM ) , PSC ( MRCP , ERCP ) • Imaging Modalities : Abd US , MRI , MRCP

21. Tests to determine specific etiology

22. Approach to Gastrointestinal Bleeding

23. Objectives of approach to GI bleeding • Ask the appropriate history and perform the physical examination necessary to safely stabilize the patient . • Emphasize the importance of hemodynamic stabilization prior to proceeding with the endoscopy. • Refer the patient with GI bleeding to Gastroenterologist at the right time and on stable condition.

24. Gastrointestinal bleeding Upper Gastrointestinal Bleeding Lower Gastrointestinal bleeding Obscure Gastrointestinal Bleeding

25. Melena: passage of black Tarry offensive stool due to Bleeding form the upper GIT proximal to ligmant of Tretiz ( > 100 ml). Basic Mechanisms: • Hyperacidity • H pylori • Vascular anomalies • Autoimmune • Malignancy Ligament of Treitz

26. Management Outline Airway  Breathing  Circulation  Decide on Admission

27. Causes of UGIB ( Hematemesis/Melena)

32. Endoscopic Diagnosis

33. Take home message • Always think of hemodynamic stability ABC • Then think to do H & P • Common things are common • Careful not to kill the patient and know when to call for somebody help • Common diseases are peptic ulcers, liver disease, drug induced and malignancy. • Decide if you admit ( ward/ICU) or discharge.

34. Causes of Lower GI Bleeding 1- Anorectal Diseases :Hemorrhoids,Anal fissures 2- Infectious Gastroentritis mixed with blood 3- Colonic Diverticulosis 4- Colonic neoplasms 5- Vascular malformations:associated with renal failure/aortic stenosis 6-Inflammatory bowel disease.

35. Lower Gastrointestinal Bleeding History: • Age,Onset,Progression,preceptating factors • Associated symptoms: poor appetite, weight loss, abdominal pain, vomiting, constipation,diarrhea,Tenesmus,Straining. • Previous: similar episodes/Investigations/treatment performed.

36. Physical Examination • Vital signs: HR,BP • Signs of anemia • Abdomen: contour,tenderness,guarding ( presence or absence) • DRE : bright red or dark blood. • CVS,Resp systems

37. Lower GI bleeding • ABC • IV lines,CBC,Blood group and crossmatching/Hold. • IV colloids if hypotension/Blood if anemia. • Imaging : CT scan- Abdomen US • Refer the pt to Gastroenterology • Colonoscopy: diagnostic and therapeutic • Angiography of the mesenteric vessels.

38. Obscure GI bleeding • Evidence of Bleeding/anemia where investigations of the upper and lower GI tracts are unrevealing. • Need to exclude findings related to the GI tract by performing upper endoscopy and colonoscopy.

39. Causes of Obscure GI bleeding • Malignancy: Small bowel neoplasm • Inflammatory:Crohn’s enteritis • Vascular: Vascular malformations • Meckel’s diverticulum • Radiation related enteritis • Small bowel ulcers ( NSAID related )

40. Investigations of Obscure GI bleeding Radiology: • CT scan/MRI abdomen & Pelvis • RBC tagged scan • Mickel’s scan Endoscopy: • Double ballon Enteroscopy • Capsule Endoscopy