I.

Approach to the Patient w/

Disorders Of the Alimentary Tract
Gastrointestinal Disease
a. Functions of the GI Tract
b. Extrinsic Modulation of Gut Function
c. Overview of GI Diseases
d. Evaluation of the px w/ GI Disease
e. Management Options

Mary Ann Tomeldan-Balatero,MD,DFM,FPAFP,FPCGM

•  The GI tract
(gastrointestinal tract)
The muscular alimentary
canal
–  Mouth
–  Pharynx
–  Esophagus
–  Stomach
–  Small intestine
–  Large intestine
–  Anus

•  The accessory
digestive organs
Supply secretions contributing
to the breakdown of food
–  Teeth & tongue * Mucosa - barrier to luminal contents
–  Salivary glands - site for transfer of fluids or nutrients.
–  Gallbladder * Gut smooth muscles - mediates propulsion from one region to the next.
–  Liver * Serosal layer - provides a supportive foundation
–  Pancreas --- also permits external input.

FUNCTIONS OF THE GASTROINTESTINAL TRACT

Function
- it takes less than an hour after a meal for 50% of stomach
contents to empty into the intestines and total emptying of the
stomach takes around 2 hours.

- 50% emptying of the small intestine takes 1 to 2 hours.

- transit through the colon takes 12 to 50 hours with wide

variation between individuals.
Immune barrier
- low pH (ranging from 1 to 4) of the stomach is
fatal for many microorganisms that enter it
--- mucus (containing IgA antibodies) neutralizes
many of these microorganism
- Other factors in the GI tract help with immune
function
--- enzymes in saliva and bile.
•  Immune system homeostasis
- Beneficial bacteria also can contribute to the gastrointestinal
system homeostasis --- Clostridia play an important role
influencing the dynamics of our immune system in the
gut
***Intestinal flora
The large intestine hosts several kinds of bacteria that deal
with molecules the human body not able to break down itself
---- account for the production of gases at host-pathogen
interface inside our intestine
(this gas is released as flatulence).
A. Impaired digestion and absorption
l diseases of the stomach, intestine, biliary tree, and
pancreas.
l lactase deficiency-- most common intestinal maldigestion
syndrome
--produces gas and diarrhea(dairy products)
l celiac disease, bacterial overgrowth, infectious enteritis,
Crohn's ileitis, and radiation damage
→ produce anemia, dehydration, electrolyte disorders,
or malnutrition.
--- Enzymes such as Cyp3A4, along with the antiporter
activities, also are instrumental in the intestine's role of
detoxification of antigens and xenobiotics.
- Health-enhancing intestinal bacteria of the gut flora serve to
prevent the overgrowth of potentially harmful bacteria in the
gut.
---- A ratio of 80-85% beneficial to 15-20% potentially
harmful bacteria generally is considered normal within the
intestines.
Microorganisms also are kept at bay by an extensive
immune system comprising the gut-associated lymphoid
tissue (GALT).
OVERVIEW OF GASTROINTESTINAL
DISEASES
n  CLASSIFICATION OF GI DISEASES
" GI diseases are manifestations of alterations in nutrient
assimilation or waste evacuation or in the activities supporting
these main functions."
l  Zollinger-Ellison syndrome
→ gastric hypersecretory condition causing damage of the
intestinal mucosa, impair pancreatic enzyme activation, and
accelerate transit due to excess gastric acid.
l  Biliary obstruction from stricture or neoplasm impairs fat
digestion.
l  chronic pancreatitis or pancreatic cancer
→ Impaired pancreatic enzyme release
→ decreases intraluminal digestion and can lead to
malnutrition.
B. Altered secretion
l  Gastric acid hypersecretion - Zollinger-Ellison syndrome,
G cell hyperplasia, retained antrum syndrome, and some
individuals with duodenal ulcers.
l  atrophic gastritis or pernicious anemia release little or no
gastric acid.
l  Common intestinal and colonic hypersecretory conditions
cause diarrhea
--- acute bacterial or viral infection, chronic Giardia or
cryptosporidia infections, small-intestinal bacterial
overgrowth, bile salt diarrhea, microscopic colitis, diabetic
diarrhea, and abuse of certain laxatives.
l  Less common causes : large colonic villus adenomas and
endocrine neoplasias with tumor overproduction of
secretagogue transmitters like vasoactive intestinal
polypeptide.
l  colon cancer - most common cause of colonic obstruction
inflammatory strictures: develop in patients with inflammatory
bowel disease(IBD), → after certain infections such as diverticulitis,
or with some drugs.
l  Achalasia is characterized by impaired esophageal body
peristalsis and incomplete lower esophageal sphincter relaxation.
l  Gastroparesis is the symptomatic delay in gastric emptying of
meals due to impaired gastric motility.
l  Intestinal pseudoobstruction causes marked delays in small-bowel transit
due to enteric nerve or intestinal smooth-muscle injury.
D. Immune dysregulation
l  celiac disease - mucosal inflammation w/c results from
dietary ingestion of gluten-containing grains.
*** patients with food allergy
l  Eosinophilic esophagitis and eosinophilic gastroenteritis
- are inflammatory disorders with prominent mucosal
eosinophils.
l  Ulcerative colitis and Crohn's disease - disorders of
uncertain etiology that produce mucosal injury primarily
in the lower gut.
l  Bacterial, viral, and protozoal organisms may produce
ileitis or colitis.
C. Altered gut transit
- Impaired gut transit may be secondary to mechanical
obstruction.
l  Esophageal occlusion: often results from acid-induced
stricture
or neoplasm.
l  Gastric outlet obstruction develops from peptic ulcer disease
or gastric cancer
l  Small-intestinal obstruction:
- most commonly results from adhesions but may also occur
with Crohn's disease,radiation- or drug-induced strictures.
- less likely malignancy.
l  Constipation: produced by outlet abnormalities such as
rectal prolapse, intussusception, or dyssynergia—a failure of
anal or puborectalis relaxation upon attempted defecation.
l  Rapid gastric emptying occurs in postvagotomy dumping
syndrome, with gastric hypersecretion, and in some cases of
functional dyspepsia and cyclic vomiting syndrome
l  irritable bowel syndrome: exaggerated intestinal or colonic
motor patterns may be responsible for diarrhea
l  Hyperthyroidism: Accelerated transit with hyperdefecation
E. Impaired gut blood flow
l  intestinal and colonic ischemia
→ consequences of arterial embolus, arterial thrombosis,
venous thrombosis, or hypoperfusion from dehydration, sepsis,
hemorrhage, or reduced cardiac output.
→ may produce mucosal injury, hemorrhage, or even
perforation.
l  radiation enterocolitis - exhibit reduced mucosal blood flow.
→ inflammation of the intestines that occurs after radiation
therapy. ----- diarrhea, nausea, vomiting and stomach cramps
in people receiving radiation aimed at the abdomen, pelvis or
rectum.
F. Neoplastic degeneration
l  Colorectal cancer is most common (United States) and
usually presents after age 50 years.
l  Gastric cancer - is prevalent especially in certain Asian
regions.
l  Esophageal cancer - develops with chronic acid reflux or
after an extensive alcohol or tobacco use history.
l  Anal cancers - arise after prior anal infection or
inflammation.
l  Pancreatic and biliary cancers - elicit severe pain, weight
loss, and jaundice and have poor prognoses.
l  Hepatocellular carcinoma - usually arises in the setting of
chronic viral hepatitis or cirrhosis secondary to other
causes.
G. Disorders without obvious organic abnormalities
l  most common GI disorders show no abnormalities on
biochemical or structural testing:
irritable bowel syndrome
functional dyspepsia
functional chest pain altered gut motor function
functional heartburn
→ Exaggerated visceral sensory responses to noxious
stimulation
→ Symptoms in other patients result from altered processing of
visceral pain sensations in the central nervous system.
→ severe symptoms may exhibit significant emotional
disturbances on psychometric testing.

H. Genetic influences SYMPTOMS OF

GASTROINTESTINAL DISEASE
l Colonic and esophageal malignancies arise in
certain inherited disorders. - most common: Others: dysphagia
abdominal pain anorexia
l genetic dysmotility syndromes - rare
heartburn weight loss
l functional bowel disorders - Familial clustering
nausea and vomi2ng fa2gue, and extraintes2nal
is even observed symptoms.
altered bowel habits
→ familial illness behavior rather than a true
GI bleeding
hereditary factor.
jaundice

u  Abdominal pain
- results from GI disease and extraintestinal conditions Abdominal Pain
involving the genitourinary tract, abdominal wall, thorax, or
spine.
- Visceral pain: midline in location and vague in character •  Appendicitis •  Inflammatory bowel
- parietal pain: localized and precisely described. •  Gallstone disease disease
- most common causes: irritable bowel syndrome and •  Pancreatitis •  Functional bowel
functional dyspepsia. disorder
- Common inflammatory diseases with pain include:
•  Diverticulitis
•  Ulcer disease •  Vascular disease
peptic ulcer, appendicitis, diverticulitis, inflammatory bowel
disease, and infectious enterocolitis. •  Esophagitis •  Gynecologic causes
- intraabdominal causes of pain include: gallstone disease and •  Renal stone
pancreatitis.
•  GI obstruction
- Noninflammatory visceral sources include:
→ mesenteric ischemia and neoplasia
u  Heartburn Ø  food → throat → esophagus →
stomach
- also known as pyrosis, cardialgia, or acid Ø  Normally → a muscular valve
indigestion called the lower esophageal
- a burning substernal sensation sphincter (LES) opens to allow
- reported intermittently by at least 40% of food into the stomach (or to
the population. permit belching); then it closes
again.
- result from excess gastroesophageal
reflux of acid Ø  Then the stomach releases
strong acids to help break down
the food.
***some cases exhibit normal esophageal Ø  But if the lower esophageal
acid exposure and may result from reflux sphincter opens too often or
of nonacidic material or heightened does not close tight enough:
sensitivity of esophageal mucosal → stomach acid can reflux or
nerves. seep back into the esophagus,
damaging it and causing the
burning sensation

u  Nausea and vomiting

Ø  Medications
Nausea: an unpleasant, queasy feeling in the throat or
stomach that may result in vomiting. Ø  GI obstruction
Vomiting: forceful emptying of the stomach contents Ø  Motor disorders
through the mouth . Ø  Functional bowel
disorder
Ø  Enteric infection
Ø  Pregnancy
Ø  Endocrine disease
Ø  Motion sickness
Ø  Central nervous system
disease

u  Altered bowel habits

u Constipation: infrequent defecation, straining with defecation,
passage of hard stools, or a sense of incomplete fecal evacuation.
- described as having fewer than three bowel movements a week.
- most commonly occurs when waste or stool moves too slowly
through the digestive tract, causing it to become hard and dry.

ü Food flows through the small intestine

as a liquid mixture of digestive juices
and the food you eat.

ü By the time it reaches the large

intestine, all the nutrients have been
absorbed.

ü The large intestine has one main

function: to absorb water from the
waste liquid, and turn it into a waste
solid (stool).
Causes: 2. Neurological problems can 3. Difficulty with the muscles 4. Condi?ons that affect
1. Blockages in the colon or affect the nerves that cause involved in elimina?on hormones in the body
muscles in the colon and - pelvic muscles
rectum - may slow or stop rectum to contract and * Hormones help balance
stool movement. move stool through the fluids in your body.
intes2nes. Ø  Inability to relax the
Ø  Anal fissure pelvic muscles to allow for a
bowel movement (anismus) Ø  Diabetes
Bowel obstruc2on Ø  Autonomic neuropathy
Mul2ple sclerosis Ø  Pelvic muscles don't Ø  Overac2ve parathyroid
Colon cancer gland (hyperparathyroidism)
Parkinson's disease coordinate relaxa2on and
Narrowing of the colon (bowel contrac2on correctly
stricture) Spinal cord injury Ø  Pregnancy
Stroke (dyssynergia)
Other abdominal cancer that Ø  Underac2ve thyroid
Ø  Weakened pelvic muscles (hypothyroidism)
presses on the colon
Rectal cancer
Rectocele

u Diarrhea: frequent defecation, passage of loose or watery

n  Prescrip2ons drugs n  Nonprescrip2on drugs
stools, fecal urgency, or a similar sense of incomplete
Pain medica2ons, par2cularly Antacids that contain aluminum
those containing opiates and calcium evacuation.
Muscle relaxants Iron supplements
An2spasmodics An2histamines Causes:
An2depressants An2diarrheal agents Infection
An2parkinson drugs Calcium supplements Poorly absorbed sugars
Blood pressure medica2ons Nonsteroidal an2-inflammatory Inflammatory bowel disease
(beta blockers and calcium agents Microscopic colitis
channel blockers) Functional bowel disorder
Diure2cs Celiac disease
An2convulsants Pancreatic insufficiency
An2psycho2c drugs Hyperthyroidism
An2histamines Ischemia
Endocrine tumor

ü  differential diagnosis of diarrhea:

l  Symptoms of uncomplicated l  symptoms of complicated
diarrhea : diarrhea : - includes infections, inflammatory causes, malabsorption,
and medications.
•  Abdominal bloa2ng or cramps •  Blood, mucus, or
•  Thin or loose stools undigested food in the ü  Irritable bowel syndrome
•  Watery stool stool - produces constipation, diarrhea, or an alternating bowel pattern.
•  Sense of urgency to have a •  Weight loss - Fecal mucus is common
bowel movement •  Fever ü  inflammatory disease - pus
•  Nausea and vomi2ng
ü  malabsorption - Steatorrhea ( excess fat in feces)
u  GI bleeding l  most common upper GI causes
Hematemesis is the vomiting of blood, which may be obviously red of bleeding:
or have an appearance similar to coffee grounds. → ulcer disease
Melena is the passage of black, tarry stools. → gastroduodenitis
Hematochezia is the passage of fresh blood per anus, usually in or → esophagitis
with stools.
n  Other etiologies include:
Ø  upper GI bleeding presents with melena or hematemesis
→ portal hypertensive causes
* briskly bleeding upper sites can elicit voluminous red → malignancy
rectal bleeding, while slowly bleeding ascending colon sites may → tears across the
produce melena. gastroesophageal junction
→vascular lesions.
Ø  lower GI bleeding produces passage of bright red or maroon
stools.
Ø  Chronic slow GI bleeding may present with iron deficiency
anemia.

l  most prevalent lower GI

sources of hemorrhage include:
u  Jaundice/ icteric
→ hemorrhoids, - yellowish pigmentation of the skin, the conjunctival membranes
over the sclerae (whites of the eyes), and other mucous membranes
→anal fissures,
caused by hyperbilirubinemia (increased levels of bilirubin in the
→ diverticula, blood).
→ ischemic colitis,
- results from prehepatic, intrahepatic, or posthepatic disease.
→ arteriovenous malformations.
Pre-hepatic/ hemolytic - pathology is occurring prior to the liver.
n  Other causes include :
Hepatic/ hepatocellular - pathology is located within the liver
→ neoplasm
Post-Hepatic/ cholestatic -pathology is located after the
→ inflammatory bowel disease conjugation of bilirubin in the liver.
→ infectious colitis
→ drug-induced colitis
→ other vascular lesions.

l  Hepatic
l  Pre-hepatic - result of increased bilirubin production.
- arise from abnormalities in the metabolism and/or excretion of
* major cause is excessive hemolysis of red blood cells bilirubin
Conditions which can lead to an increase in the hemolysis of red - lead to increase in both unconjugated and/or conjugated bilirubin
blood cells include: levels.
•  Malaria, - Conditions with a hepatic cause of jaundice include:
•  Sickle cell disease,
•  Hereditary spherocytosis, Acute or chronic hepatitis (commonly viral [Hepatitis A, B, C, D, E]
or alcohol related),
•  Thalassemia,
Cirrhosis (caused by various conditions),
•  Glucose-6-phosphate dehydrogenase deficiency (G6PD),
Drugs or other toxins,
•  Drugs or other toxins, and
Crigler-Najjar syndrome,
•  Autoimmune disorders. Autoimmune disorders,
Gilbert's syndrome, and
Liver cancer.
l  Post-hepatic
- arises from a disruption (an obstruction) in the normal drainage and
excretion of conjugated bilirubin in the form of bile from the liver
into the intestine
- leads to increased levels of conjugated bilirubin in the bloodstream
- Conditions that can cause post-hepatic jaundice include:
Gallstones,
Malignancy (pancreatic cancer, gallbladder cancer and bile duct
cancer),
Strictures of the bile ducts,
Cholangitis,
Pancreatitis, and
Parasites (for example, liver flukes)
Ø  Inflammatory bowel disease is associated with hepatobiliary
dysfunction, skin and eye lesions, and arthritis.
Ø  Celiac disease may present with dermatitis herpetiformis.
Ø  Systemic lupus may cause gut ischemia, presenting with pain or
bleeding.
Ø  Overwhelming stress or severe burns may lead to gastric ulcer
formation.
Ø  Symptom patterns and duration
- Ulcer pain occurs at intermittent intervals lasting weeks to months,
while biliary colic has a sudden onset and lasts up to several hours.
→type of pain related to the gallbladder that occurs when a
gallstone transiently obstructs the cystic duct and the gallbladder
contracts
- Pain from acute inflammation --- acute pancreatitis is severe and
persists for days to weeks.
- Meals elicit diarrhea in some cases of inflammatory bowel disease
and irritable bowel syndrome.
- Defecation relieves discomfort in inflammatory bowel disease and
irritable bowel syndrome.
- Functional bowel disorders are exacerbated by stress.
- Diarrhea from malabsorption usually improves with fasting, while
secretory diarrhea persists without oral intake.
u  Other symptoms
Ø  Dysphagia, odynophagia, and unexplained chest pain
→ suggest esophageal disease.
Ø  globus sensation - Globus pharyngis, globus hystericus
- lump in one's throat
- caused by inflammation of one or more parts of the throat, such as
the larynx or hypopharynx, due to Cricopharyngeal Spasm,
gastroesophageal reflux (GERD), Laryngopharyngeal reflux or
esophageal versatility.
- psychogenic cause i.e. a somatoform or anxiety disorder
Ø  Weight loss, anorexia, and fatigue --- nonspecific symptoms of
neoplastic, inflammatory, gut motility, pancreatic, small-bowel
mucosal, and psychiatric conditions.
EVALUATION OF THE PATIENT WITH
GASTROINTESTINAL DISEASE
n  HISTORY
Ø  Symptom timing
- short duration commonly result from acute infection,
toxin exposure, or abrupt inflammation or ischemia.
- Long-standing symptoms- chronic inflammatory or neoplastic
conditions or functional bowel disorders.
- Symptoms from mechanical obstruction, ischemia,
inflammatory bowel disease, and functional bowel disorders
→ worsened by meals.
- ulcer symptoms may be relieved by eating or antacids.
Ø  Symptom rela,on to other factors
- Obstruc2ve symptoms with prior abdominal surgery
raise concern for adhesions.
- loose stools aYer gastrectomy or gallbladder excision suggest
dumping syndrome or post cholecystectomy diarrhea.
Ø  Symptom onset a2er travel prompts a search for enteric infec2on.
Ø  Lower GI bleeding likely results from neoplasms, diver2cula, or
vascular lesions in an older person
----- anorectal abnormali2es or inflammatory bowel
disease in a younger individual.
p Rome criteria
- symptom criteria of func2onal bowel disorders
- exhibit diagnos2c specifici2es exceeding 90% for many of the
func2onal bowel disorders.
p Rome criteria
- is a system developed to classify the functional
gastrointestinal disorders (FGIDs)
- disorders of the digestive system in which symptoms cannot
be explained by the presence of structural or tissue
abnormality, based on clinical symptoms.
- include irritable bowel syndrome, functional dyspepsia,
functional constipation, and functional heartburn.
- recent revision of the criteria---- the Rome III criteria
n  PHYSICAL EXAMINATION
Ø  Fever suggests inflammation or neoplasm.
Ø  Orthostasis is found with significant blood loss,
dehydration, sepsis, or autonomic neuropathy.
Ø  Neck exam with swallowing assessment evaluates
dysphagia.
Ø  Cardiopulmonary disease may present with abdominal pain
or nausea → lung and cardiac exams are important.
Ø  Rectal exam may detect blood, indicating gut mucosal
injury or neoplasm or a palpable inflammatory mass in
appendicitis.

Ø  Inspection of the abdomen Ø  Auscultation can detect bruits or friction rubs from vascular
--- distention → from obstruction, tumor, or ascites or disease or hepatic tumors.
vascular abnormalities with liver disease - Loss of bowel sounds → ileus
- high-pitched, hyperactive sounds → intestinal obstruction.

Ø  Percussion assesses liver size and can detect shifting

--- Ecchymoses develop with severe pancreatitis. dullness from ascites.
Ø  Palpation assesses for hepatosplenomegaly as well as
neoplastic or inflammatory masses.

Ø  Intestinal ischemia elicits severe pain but little tenderness.

Ø  Patients with visceral pain may exhibit generalized TOOLS FOR PATIENT EVALUATION
discomfort,
while those with parietal pain or peritonitis have directed ü  Laboratory •  SEROLOGY
pain, often with involuntary guarding, rigidity, or rebound. •  Complete Blood Count Anti-HCV
•  Glucose Hepatitis B Screening
Patients with musculoskeletal abdominal wall pain may note •  Creatinine HBsAg
tenderness exacerbated by Valsalva or straight-leg lift
•  Uric Acid Anti HBc (Total)
maneuvers.
•  Cholesterol
straight-leg lift--- Lasègue's sign, Lasègue test or
•  Blood Urea Nitrogen •  Urinalysis
Lazarević's sign,
•  Triglycerides •  Routine Stool
- is a test done during the physical examination to determine
whether a patient with low back pain has an underlying •  HDL
herniated disk, often located at L5 (fifth lumbar spinal nerve). •  LDL/VLDL
•  SGPT/ALT
n  TOOLS FOR PATIENT EVALUATION - Pregnancy testing is considered for women with unexplained
ü  Laboratory nausea.
- Leukocytosis and increased sedimentation rates and C- - Serologic tests can screen for celiac disease, inflammatory
reactive proteins are found in inflammatory conditions. bowel disease, rheumatologic diseases like lupus or
scleroderma, and paraneoplastic dysmotility syndromes.
- leukopenia is seen in viremic illness.
- Ascitic fluid is analyzed for infection, malignancy, or findings of
- Severe vomiting or diarrhea elicits electrolyte disturbances,
portal hypertension.
acid-base abnormalities, and elevated blood urea nitrogen.
- Urine samples screen for carcinoid, porphyria, and heavy
- vitamin B 12 deficiency results from small-intestinal, gastric, or metal intoxication.
pancreatic disease.
- Pancreaticobiliary or liver disease is suggested by elevated
pancreatic or liver chemistries.
- carcinoembryonic antigen CA 19-9 and α-fetoprotein
--- Intraabdominal malignancies

ü  Luminal contents
ü  Endoscopy
- Stool samples: cultured for bacterial pathogens, examined for
- can provide the diagnosis of the causes of bleeding, pain,
leukocytes and parasites, or tested for Giardia antigen. nausea and vomiting, weight loss, altered bowel function,
- Duodenal aspirates can be examined for parasites or cultured and fever.
for bacterial overgrowth. p  Upper endoscopy evaluates the esophagus, stomach,
- Fecal fat is quantified in possible malabsorption and duodenum.
- Stool electrolytes can be measured in diarrheal conditions. - Dyspepsia despite treatment
- Laxative screens are done when laxative abuse is suspected. - Dyspepsia with signs of organic disease
- Refractory vomiting
- Esophageal pH testing is done for refractory symptoms of
acid reflux - Dysphagia
- Pancreatic juice is analyzed for enzyme or bicarbonate - Upper GI bleeding
content to exclude pancreatic exocrine insufficiency. - Anemia
- Weight loss
- Malabsorption

- Biopsy radiologic abnormality p Colonoscopy

- Polypectomy --- is the procedure of choice for colon cancer screening and
- Place gastrostomy surveillance as well as diagnosis of colitis secondary to
- Barrett’s surveillance infection, ischemia, radiation, and inflammatory bowel
disease.
- Palliate neoplasm
- Sample duodenal tissue/fluid Cancer screening Palliate neoplasm
- Remove foreign body Lower GI bleeding Remove foreign body
- Endoscopic mucosal Anemia
- resection or ablation of dysplastic Barrett’s mucosa Diarrhea Place stent across stenosis
Polypectomy
- Place stent across stenosis
Obstruc?on
Biopsy radiologic
abnormality
Cancer surveillance: family history prior
polyp/cancer, coli?s
 p  Sigmoidoscopy
- examines the colon up to the splenic flexure
- currently used to exclude distal colonic inflammation or
obstruction in young patients not at significant risk for colon
cancer.

ü  For elusive GI bleeding secondary to arteriovenous p Endoscopic retrograde

malformations or superficial ulcers, small-intestinal cholangiopancreaticography(ERCP)
- technique that combines the use of
examination is performed ---- push enteroscopy endoscopy and fluoroscopy to
capsule endoscopy- Crohn’s diagnose and treat certain problems of
the biliary or pancreatic ductal
disease systems.
double-balloon enteroscopy
→Biopsy of suspicious small Jaundice
Postbiliary surgery Fistulas
intestinal masses/ ulcers
complaints Biopsy radiologic
Cholangitis abnormality
Gallstone pancreatitis Sample bile
Pancreatic/biliary/ampullary Sphincter of Oddi
tumor manometry
Unexplained pancreatitis
Pancreatitis with unrelenting pain
Pancreaticobiliary drainage

p  Endoscopic ultrasound
ü  Radiography/nuclear medicine
- most commonly used in the upper digestive tract and in the
respiratory system u Radiographic tests - evaluate diseases of the gut and
- Staging of malignancy extraluminal structures.
- Characterize and biopsy submucosal mass l  Oral or rectal contrast: barium agents provide mucosal
- Bile duct stones definition from the esophagus to the rectum.
- Chronic pancreatitis l  Barium swallow - initial procedure for evaluation of
- Drain pseudocyst dysphagia to exclude subtle rings or strictures and assess for
- Large gastric folds achalasia.
- Anal continuity l  small-bowel contrast radiology reliably diagnoses intestinal
tumors and Crohn’s ileitis.
l  Contrast enemas : performed when colonoscopy
is unsuccessful or contraindicated.
 u  Ultrasound and computed tomography (CT)
- evaluate regions not accessible by endoscopy or contrast
studies
→ including the liver, pancreas, gallbladder, kidneys,
achalasia and retroperitoneum.
→ useful for diagnosis of mass lesions, fluid collections,
organ enlargement, and in the case of ultrasound gallstones.

small bowel obstruction kidney stones

Healthy liver u  CT and magnetic resonance (MR) colonography are being

evaluated as alternatives to colonoscopy for colon cancer
Fatty Liver
screening.
the black area is fat MR imaging assesses the pancreaticobiliary ducts to exclude
that covers the liver
neoplasm, stones, and sclerosing cholangitis, and the liver
to characterize benign and malignant tumors.

CT scan: tumour of the

pancreatic head
pancreatic carcinoma
gallstones localized in the head of the
pancreas

u  Angiography u  Histopathology
- access the biliary tree in obstructive jaundice. Deep rectal biopsies assist with diagnosis of Hirschsprung's
disease or amyloid.
u Positron emission tomography( PET) Liver biopsy - indicated in cases with abnormal liver chemistries,
- can facilitate distinguishing malignant from benign disease - unexplained jaundice, following liver transplant to
in several organ systems. exclude rejection,
- and to characterize the degree of inflammation
Scintigraphy in patients with chronic viral hepatitis prior to
- both evaluates structural abnormalities and quantifies initiating antiviral therapy.
luminal transit.
u  Functional testing
- gastric acid and pancreatic function testing
- Esophageal manometry - suspected achalasia
- wireless motility capsule - measure transit and contractile
activity in the stomach, small intestine, and colon in a single
test.
- Anorectal manometry with balloon expulsion testing
- unexplained incontinence or constipation from outlet
dysfunction.
- Biliary manometry tests for sphincter of Oddi dysfunction
with unexplained biliary pain.
- Measurement of breath hydrogen while fasting and after oral
mono- or oligosaccharide challenge can screen for
carbohydrate intolerance and small-intestinal bacterial
overgrowth.
•  Dietary Modifications:
lactase deficiency- lactose restriction
gastroparesis - liquid meals
dumping syndrome- carbohydrate restrictions
irritable bowel syndrome- high-fiber diets
celiac disease - gluten-free diet exemplifies a modification
that serves as primary therapy to reduce
mucosal inflammation.
gastrostomy - liquid meals
jejunostomy is considered for gastric dysmotility syndromes
that preclude feeding into the stomach.
Intravenous hyperalimentation
•  Prescription Drugs
Prokinetic drugs stimulate GI propulsion in gastroparesis and
pseudoobstruction.
antidiarrheals include opiate drugs, anticholinergic
antispasmodics, tricyclics, bile acid binders, and serotonin
antagonists.
Antispasmodics and antidepressants also are useful for
functional abdominal pain,
narcotics are used for pain control in organic conditions such
as disseminated malignancy and chronic pancreatitis.
Antisecretory drugs- somatostatin analogue octreotide treat
hypersecretory states.
Antibiotics treat ulcer disease secondary to Helicobacter
pylori , infectious diarrhea, diverticulitis, intestinal bacterial
overgrowth, and Crohn's disease.
Chemotherapy with or without radiotherapy is offered for GI
malignancies.
•  TREATMENT Gastrointestinal Disease
→ modifications in dietary intake
→ medications
→ interventional endoscopy or radiology
techniques
→ surgery
→ therapies directed to external influences.
•  PHARMACOTHERAPY
Over-the-Counter Agents : mild GI symptoms
→Antacids and histamine H 2 antagonists
→decrease symptoms in gastroesophageal reflux and
dyspepsia
→antiflatulents and adsorbents reduce gaseous symptoms
→proton pump inhibitors - treatment of chronic
gastroesophageal reflux disease (GERD).
→Fiber supplements, stool softeners, enemas, and laxatives
are used for constipation.
→antidiarrheal agents include bismuth subsalicylate, kaolin-
pectin combinations, and loperamide.
u  ENTERIC THERAPIES/INTERVENTIONAL ENDOSCOPY AND
RADIOLOGY
→Nasogastric tube suction: decompresses the upper gut in ileus or
mechanical obstruction
→Nasogastric lavage of saline or water : upper GI hemorrhage determines
the rate of bleeding and helps evacuate blood prior to endoscopy.
→Enemas relieve fecal impaction or assist in gas evacuation in acute
colonic pseudoobstruction
→rectal tube can be left in place to vent the distal colon in colonic
pseudoobstruction and other colonic distention disorders
→endoscopy: Cautery techniques
Injection with vasoconstrictor substances or sclerosants
Endoscopic encirclement of varices and hemorrhoids with
constricting bands insert feeding tubes.
•  Radiologic
→Angiographic embolization or vasoconstriction decreases bleeding from
sites not amenable to endoscopic intervention.
→CT and ultrasound help drain abdominal fluid collections
→Percutaneous transhepatic cholangiography relieves biliary
obstruction when ERCP is contraindicated.
→Lithotripsy can fragment gallstones in patients who are not candidates for
surgery GASTROINTESTINAL ENDOSCOPY
•  SURGERY
→mandated for ulcer complications such as bleeding, obstruction, or
perforation and intestinal obstructions that persist after conservative care
Achalasia responds to operations to relieve lower esophageal sphincter
pressure.
•  THERAPY DIRECTED TO EXTERNAL INFLUENCES
Psychological therapies : psychotherapy, behavior modification, hypnosis,
and biofeedback have shown efficacy in functional bowel disorders

ENDOSCOPIC PROCEDURES
n  UPPER ENDOSCOPY
a) Duodenal ulcers
- esophagogastroduodenoscopy (EGD)

- performed by passing a flexible endoscope through the mouth

into the esophagus, stomach, bulb, and second duodenum.

- best method of examining the upper gastrointestinal mucosa.

- it permits directed biopsy and endoscopic therapy.

Ulcer with a clean
base Ulcer with a visible vessel
- is superior for detection of: (arrow ) in a patient with recent
hemorrhage.

c) Barrett’s esophagus
b) gastric ulcers - flat mucosal lesions

Barrett’s
esophagus with
a suspicious
nodule (arrow)

Pink tongues of Barrett’s mucosa

extending proximally from the
gastroesophageal junction
Benign gastric ulcer
Malignant gastric
ulcer involving greater curvature of intramucosal
stomach. adenocarcinoma in
the endoscopically
resected nodule.

Tumor extends into the esophageal submucosa Barrett’s esophagus with locally
(arrow) advanced adenocarcinoma.
n  UPPER ENDOSCOPY
n  COLONOSCOPY
- Intravenous conscious sedation (US)--- to ease the anxiety - performed by passing a flexible colonoscope through the anal
and discomfort of the procedure canal into the rectum and colon.
- cecum is reached in >95% of cases, and the terminal ileum
- although in many countries --- routinely performed with topical can often be examined.
pharyngeal anesthesia only.
- gold standard for diagnosis of colonic mucosal disease.
- Patient tolerance of unsedated EGD is improved by the use of - has greater sensitivity than barium enema for
an ultrathin, 5-mm diameter endoscope that can be passed colitis, polyps and cancer.
transorally or transnasally.

a) colitis b) polyps
c) Cancer
Chronic
ulcerative colitis
with diffuse
ulcerations and
exudates.

Severe Crohn’s colitis with deep

ulcers Pedunculated colon polyp on a
thick stalk covered with normal Colon adenocarcinoma growing
mucosa (arrow ). into the lumen

Sessile rectal
Pseudomembranous colitis Ischemic colitis with patchy mucosal polyp
with yellow, adherent edema, subepithelial hemorrhage,
pseudomembranes and cyanosis.

ü  colonography is an emerging technology that rivals n  FLEXIBLE SIGMOIDOSCOPY

colonoscopy’s accuracy for detection of polyps and cancer.
ü  Conscious sedation is usually given before colonoscopy in
the United States
ü  although a willing patient and a skilled examiner can
complete the procedure without sedation in many cases.
- similar to colonoscopy but visualizes only the rectum and
a variable portion of the left colon, typically to 60 cm from
the anal verge.
- procedure causes abdominal cramping
- brief and is usually performed without sedation.
- primarily used for evaluation of diarrhea and rectal outlet
bleeding.

internal
hemorrhoids
Ø  A 68-year-old woman had watery,
yellowish diarrhea with mucus and
left lower quadrant pain.
Ø  Her medical history included
hypertension, diabetes mellitus, Diagnosis:
and congestive heart failure.
Ø  A flexible sigmoidoscopy revealed
edema and erythema of the
rectosigmoid mucosa with multiple
yellowish plaques
(pseudomembranes).
•  Clostridium difficile toxin
n  SMALL-BOWEL ENDOSCOPY
was found in the stool.
Ø  Three techniques are currently used to evaluate the small intestine,
most often in patients presenting with presumed small-bowel
Pseudomembranous bleeding.
enterocolitis
a) capsule endoscopy
→ patient swallows a disposable capsule that contains a complementary
metal oxide silicon (CMOS) chip camera.
enables visualization of the jejunal and ileal
mucosa beyond the reach of a conventional
endoscope

Color still images are transmitted wirelessly

to an external receiver at several frames per
second until the capsule’s battery is exhausted
or it is passed into the toilet.

jejunal vascular ectasia

b) Push enteroscopy c) single- or double-balloon enteroscopy or spiral

- performed with a long endoscope similar in design to an
upper endoscope.
- The enteroscope is pushed down the small bowel, sometimes
with the help of a stiffening overtube that extends from the
mouth to the small intestine.
- The proximal to mid-jejunum is usually reached, and the
endoscope’s instrument channel allows for biopsies or
endoscopic therapy.
enteroscopy
- balloon-assisted enteroscopy --- the entire small bowel can be visualized
in some patients when both the oral and anal routes of insertion are
used.
- Biopsies and endoscopic therapy can be performed throughout the
visualized small bowel.

Radiograph of a double-balloon enteroscope in the

small intestine.

Nonsteroidal anti-inflammatory (NSAID)-induced proximal ileal n  ENDOSCOPIC RETROGRADE

stricture diagnosed by double-balloon endoscopy. CHOLANGIOPANCREATOGRAPHY (ERCP)
Ø  is passed through the mouth to the duodenum,
Ø  the ampulla of Vater is identified and cannulated with a thin plastic
catheter,
Ø  and radiographic contrast material is injected into the bile duct and
pancreatic duct under fluoroscopic guidance.

(ERCP) for bile duct stones with cholangitis.

A . Ileal stricturecausing obstructive symptoms. A. Faceted bile duct stones

B. Balloon dilatation of the ileal stricture. are demonstrated in the common bile duct.
C. Appearance of stricture after dilatation.
B. After endoscopic sphincterotomy,
the stones are extracted with a Dormia
basket. A small abscess
communicates with the left hepatic duct.
the sphincter of Oddi can be opened using the technique of
endoscopic sphincterotomy
Endoscopic retrograde cholangiopancreatography
(ERCP) in a patient with obstructive jaundice
demonstrates a malignantappearing
stricture of the biliary confluence extending into the left
and right intrahepatic ducts.

A normal-appearing
Sphincterotomy is performed with
ampulla of Vater.
electrocautery

Endoscopic placement of bilateral self-expanding

metal stents (arrow) relieves the biliary obstruction

Bile duct stones are extracted with a

Final appearance
balloon catheter
of the sphincterotomy.

n  ENDOSCOPIC ULTRASOUND (EUS) - also useful for diagnosis of bile duct stones, gallbladder
disease, submucosal gastrointestinal lesions, and chronic
- utilizes high-frequency ultrasound transducers incorporated pancreatitis.
into the tip of a flexible endoscope. - Fine-needle aspirates and core biopsies of masses and
lymph nodes in the posterior mediastinum, abdomen, pancreas,
- Ultrasound images are obtained of the gut wall and adjacent retroperitoneum, and pelvis
organs, vessels, and lymph nodes.

- provides the most accurate preoperative local staging of

esophageal, pancreatic, and rectal malignancies
---does not detect most distant metastases.

- also useful for diagnosis of bile duct stones, gallbladder

disease, submucosal gastrointestinal lesions, and chronic
pancreatitis.
Ø  Ultrasound image of a 22-gauge needle passed
through the duodenal wall and positioned in a
hypoechoic pancreatic head
mass.

n  NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY n  RISKS OF ENDOSCOPY

(NOTES)
- an evolving collection of endoscopic methods that entail
passage of an endoscope or its accessories through the wall
of the gastrointestinal tract to perform diagnostic or
therapeutic interventions.
- procedures: percutaneous endoscopic gastrostomy (PEG) or
endoscopic necrosectomy of pancreatic necrosis,
Ø  Medications used during conscious sedation may cause
respiratory depression or allergic reactions.
Ø  All endoscopic procedures carry some risk of bleeding and
gastrointestinal perforation.
→ risks are quite low with diagnostic upper endoscopy and
colonoscopy (<1:1000 procedures)
→ risk is as high as 2:100 when therapeutic procedures such as
polypectomy, control of hemorrhage, or stricture dilatation are
performed.

Ø  Bleeding and perforation are rare with flexible sigmoidoscopy

Ø  risks for diagnostic EUS (without needle aspiration) are
similar to the risks for diagnostic upper endoscopy.

URGENT ENDOSCOPY
n  ACUTE GASTROINTESTINAL HEMORRHAGE
Endoscopy is an important diagnostic and therapeutic
technique for patients with acute gastrointestinal
hemorrhage.
ü  Initial evaluation of the bleeding patient:
- postural vital signs-- resting hypotension
- the frequency of hematemesis or melena, and (in some
cases) findings on nasogastric lavage
- those requiring blood transfusions.
→ Decreases in hematocrit and hemoglobin lag behind the
clinical course and are not reliable gauges of the magnitude
of acute bleeding.
→ Endoscopy should be performed:
- resuscitated with intravenous fluids and transfusions
-- coagulopathy or thrombocytopenia
- Tracheal intubation for airway protection should be
considered before upper endoscopy in patients with repeated
recent hematemesis and suspected variceal hemorrhage.
→ Colonoscopy has a higher diagnostic yield than radionuclide
bleeding scans or angiography in lower gastrointestinal
bleeding, and endoscopic therapy can be applied in some
cases.
→anal and rectal mucosa should be visualized endoscopically
early in the course of massive rectal bleeding----
as bleeding lesions in or close to the anal canal may be
identified that are amenable to endoscopic or surgical
transanal hemostatic techniques.
Ø  Pancreatitis occurs in about 5% of patients undergoing ERCP
and in up to 25% of patients with sphincter of Oddi
dysfunction
Ø  Ascending cholangitis, pseudocyst infection, retroperitoneal
perforation, and abscess may occur as a result of ERCP.
Ø  Percutaneous gastrostomy tube placement during EGD is
associated with a 10–15% incidence of complications, most
often wound infections.
Ø  gastrostomy tube placement --- Fasciitis, pneumonia,
bleeding, buried bumper syndrome, and colonic injury may
result from
→ patients with cirrhosis, coagulopathy, respiratory or renal
failure, and those over 70 years of age are more likely to
have significant rebleeding.
→ ≥ 90% of patients with melena are bleeding proximal to the
ligament of Treitz
→ 90% of patients with hematochezia are bleeding from the
colon.
→ Melena can result from bleeding in the small bowel or right
colon, especially in older patients with slow colonic transit.
→ massive hematochezia may be bleeding from an upper
gastrointestinal source: gastric Dieulafoy’s lesion or
duodenal ulcer, with rapid intestinal transit.
Peptic ulcer
u Gastric antral ulcer with a clean base
- low, 3–5% risk of rebleeding
- patients with melena and a clean-based
ulcer are often discharged
home from the emergency room or
endoscopy suite if they are young,
reliable, and otherwise healthy.
u Duodenal ulcer with flat pigmented
spots
- 10 and 20% risk of rebleeding
u Duodenal ulcer with a dense Ø  Endoscopic therapy of ulcers with high-risk stigmata typically
adherent clot
lowers the rebleeding rate to 5–10%
- Endoscopic therapy
Ø  hemostatic techniques: injection of epinephrine or a
sclerosant into and around the vessel, “coaptive
coagulation” of the vessel in the base of the ulcer using a
u Gastric ulcer with a pigmented thermal probe that is pressed against the site of bleeding,
protuberance/visible vessel placement of hemoclips, or a combination of these
- risk of rebleeding from the ulcer is modalities.
40%.
- endoscopic therapy to decrease the
rebleeding rate Ø  administration of a proton pump inhibitor decreases the risk
of rebleeding and improves patient outcome.

u Duodenal ulcer with active spurting

- seen with >90% risk of ongoing
bleeding without therapy.

Ø  therapies that decrease portal pressure

Varices
Ø  Two complementary strategies guide therapy of bleeding
varices:
→ local treatment of the bleeding varices
→ treatment of the underlying portal hypertension
Local therapies: endoscopic variceal
sclerotherapy,
endoscopic variceal band ligation, and
balloon tamponade with a Sengstaken-
Blakemore tube
effectively control acute hemorrhage in most
patients
--- pharmacologic treatment, surgical shunts, or radiologically
placed intrahepatic portosystemic shunts
Ø  Endoscopic variceal ligation (EVL)
- prevention of a first bleed from
large esophageal varices
*beta blockers are contraindicated
- also the preferred endoscopic therapy
for control of active esophageal variceal
bleeding and for subsequent eradication
of esophageal varices (secondary
prophylaxis)
- controls acute hemorrhage in up to 90% of patients

ü  a varix is suctioned into a cap ü  Endoscopic variceal sclerotherapy

fitted on the end of the (EVS)
endoscope, and a rubber band - involves the injection of a
is released from the cap, sclerosing, thrombogenic solution
ligating the varix into or next to the esophageal
varices.
ü  Complications: postbanding
- also controls acute hemorrhage in
ulcer bleeding and esophageal most patients
stenosis--- uncommon. - has a higher complication rate than
EVL.
- used when varices are actively
bleeding during endoscopy or
(more commonly)
when varices are the only
identifiable cause of acute
hemorrhage.
l  Gastric fundic varices Dieulafoy’s lesion
- best treated with endoscopic - also called persistent caliber artery
cyanoacrylate (“glue”) injection - a large-caliber arteriole that runs immediately beneath the
- Complications: include infection gastrointestinal mucosa and bleeds through a pinpoint
and glue embolization to other mucosal erosion
organs, such as the lungs,
brain, and spleen.

- most commonly on the lesser curvature of the proximal

stomach, causes impressive arterial hemorrhage,
- often recognized only after repeated endoscopy for recurrent
bleeding.

- Endoscopic therapy--- thermal coagulation Mallory-Weiss tear

- is typically effective for control of bleeding and ablation of
the underlying vessel once the lesion has been identified.
- Rescue therapies:
--- angiographic embolization or surgical oversewing
→ are considered in situations where endoscopic
therapy has failed.
- linear mucosal rent near or across the gastroesophageal
junction that is often associated with retching or vomiting.
- an actively bleeding tear can be treated endoscopically with
epinephrine injection, coaptive coagulation, band ligation, or
hemoclips.

Ø  74 year-old woman who presented

with acute hematemesis
Ø  pulsatile bleeding just below the
esophagogastric junction
Ø  bleeding responded well to heater-
probe cauterization

Vascular ectasias Cecal vascular ectasias (senile lesions)

- flat mucosal vascular anomalies

- cause slow intestinal blood loss and occur either in a sporadic
fashion or in a well-defined pattern of distribution
- gastric antral vascular ectasia (GAVE) or
“watermelon stomach”---characterized by stripes of Radiation-induced vascular ectasias of
the rectum in a patient previously treated
prominent flat or raised vascular for prostate cancer
ectasias

Ø responsive to local endoscopic ablative therapy, such as argon plasma

coagulation
Ø  patients may benefit from deep enteroscopy with endoscopic therapy,
pharmacologic treatment with octreotide or estrogen/progesterone therapy, or
intraoperative enteroscopy.
 Colonic diverticula
Diverticula form where nutrient arteries
penetrate the muscular wall of the colon en
route to the colonic mucosa
The artery found in the base of a diverticulum
may bleed, causing painless and
impressive hematochezia.
Ø Colonoscopy is indicated in patients with
hematochezia and suspected diverticular
hemorrhage.
Ø an actively bleeding diverticulum may be seen
and treated during colonoscopy
Acute esophageal obstruction
Esophageal food (meat) impaction
Ø  endoscopic emergency
Ø  patient may develop esophageal
ulceration, ischemia, and perforation.
Ø Patients with persistent esophageal
obstruction often have hypersalivation and
are usually unable to swallow water
Ø Radiographs of the chest and neck should
be considered before endoscopy in patients
with fever, obstruction for ≥24 h, or
ingestion of a sharp object such as a
fishbone
*Occasionally---sublingual nifedipine or
nitrates, or intravenous glucagon, may
resolve an esophageal food impaction
Malignant gastric outlet obstruction can
be relieved with endoscopically placed
expandable stents in patients with
inoperable malignancy.
n  GASTROINTESTINAL OBSTRUCTION AND
PSEUDOOBSTRUCTION
- Esophageal, gastroduodenal, and colonic obstruction or
pseudoobstruction can all be diagnosed and often managed
endoscopically.
- exception is small bowel obstruction due to surgical adhesions,
which is generally not diagnosed or treated endoscopically.
Gastric outlet obstruction
- commonly caused by gastric, duodenal, or pancreatic
malignancy, or chronic peptic ulceration with stenosis of the
pylorus.
- Patients vomit partially digested food many hours after eating.
- Gastric decompression with a nasogastric tube and
subsequent lavage for removal of retained material is the
first step in treatment.
- diagnosis can then be confirmed with a saline load test, if
desired
- Endoscopy is useful for diagnosis and treatment.
Colonic obstruction and pseudoobstruction
Ø  present with abdominal distention and discomfort;
tympany; and a dilated, air-filled colon on plain abdominal
radiography.
Ø  Acute colonic pseudoobstruction is a form of colonic ileus
that is usually attributable to electrolyte disorders,
narcotic and anticholinergic medications, immobility
(as after surgery), and retroperitoneal hemorrhage or mass.
Sigmoid volvulus with the characteristic
radiologic appearance of a “bent inner
tube.”
 Acute colonic pseudoobstruction ACUTE BILIARY OBSTRUCTION
Acute colonic dilatation occurring in a
patient soon after knee surgery
- steady, severe pain that occurs when a gallstone acutely
obstructs the common bile duct
Colonoscopic placement of
decompression tube with marked - diagnosis of a ductal stone is suspected when the patient is
improvement in colonic dilatation. jaundiced or when serum liver tests or pancreatic enzyme levels
Obstructing colonic carcinoma are elevated
Radiograph of - confirmed by direct cholangiography (performed
expanded stent endoscopically, percutaneously, or during surgery).
across the
obstructing tumor - ERCP is currently the primary means of diagnosing and
with a residual waist treating common bile duct stones in most hospitals in the
Ø Colonic adenocarcinoma causing (arrow ). United States
marked luminal narrowing of the
descending colon.
Ø Endoscopic placement of a self-
expanding metal stent

•  Ascending cholangitis
Methods of bile duct imaging
- Charcot’s triad: jaundice, abdominal pain, and fever
→ is present in about 70% of patients with ascending cholangitis and
biliary sepsis.
portal
vein - managed initially with fluid resuscitation and intravenous antibiotics
- Abdominal ultrasound is often performed to assess for gallbladder stones
common and bile duct dilation
bile duct
- Reynolds’s pentad: Charcot’s triad, shock and confusion

bile duct
stones
Endoscopic ultrasound ←
Magnetic resonance
Gallstone pancreatitis
Helical computed
(EUS) cholangiopancreatography
tomography (CT) - Urgent ERCP decreases the morbidity rate
(MRCP).
ERCP --- limited to patients with a retained bile duct stone
(MRCP) and EUS are >90% accurate and have an important role in
diagnosis. - initial MRCP or EUS for diagnosis decreases the utilization of ERCP
in gallstone pancreatitis and improves clinical outcomes by limiting the
ERCP occurrence of ERCP related complications.
- suspicion for a bile duct stone is high and urgent treatment is required
(as in a patient with obstructive jaundice and biliary sepsis)
- is the procedure of choice, since it remains the gold standard for diagnosis and
allows for immediate treatment

ELECTIVE ENDOSCOPY n  GASTROESOPHAGEAL REFLUX DISEASE (GERD)

n  DYSPEPSIA - water brash and substernal heartburn
- Endoscopy is a sensitive test for diagnosis of esophagitis
- chronic or recurrent burning discomfort or pain in the upper
abdomen that may be caused by diverse processes such as Causes of esophagitis
gastroesophageal reflux, peptic ulcer disease, and “nonulcer
Cytomegalovirus
dyspepsia,” Severe reflux
esophagitis
esophagitis with
mucosal ulceration
- disorders of motility, sensation, and somatization and friability.

- Gastric and esophageal malignancies are less common

Candida
causes of dyspepsia. esophagitis with
Herpes simplex virus
esophagitis with target- white plaques
adherent to the
- endoscopy can be a useful diagnostic tool--- weight loss or type shallow ulcerations esophageal
iron deficiency anemia mucosa.
 - most sensitive test for diagnosis of GERD is 24-h ambulatory
pH monitoring
--- Endoscopy: is indicated in patients with reflux symptoms
refractory to
antisecretory therapy
: dysphagia, weight loss, or gastrointestinal
bleeding
- Endoscopy may be considered in patients with long-standing
(≥10 years) GERD with frequent symptoms
→ as they have a sixfold increased risk of harboring
Barrett’s esophagus compared to a patient with <1 year of
reflux symptoms.
n  DYSPHAGIA
- 50% of patients presenting with difficulty swallowing have a mechanical
obstruction
- motility disorder, such as achalasia or diffuse esophageal spasm
Esophageal strictures
--- typically cause progressive dysphagia,
first for solids, then for liquids; motility disorders
often cause intermittent dysphagia for both
solids and liquids.
Ø  presence of linear furrows and multiple
corrugated rings throughout a narrowed
esophagus ( feline esophagus ) should raise
suspicion for eosinophilic esophagitis, an
increasingly recognized cause for recurrent
dysphagia and food impaction
Ø  When transfer dysphagia is evident or an
esophageal motility disorder is suspected,
esophageal radiography and/or a video-
an impacted grape at the narrowed
swallow study are the best initial diagnostic
esophagogastric junction
tests.
n  PEPTIC ULCER
- causes epigastric gnawing or burning, often occurring nocturnally and
promptly relieved by food or antacid
- endoscopy is the most sensitive diagnostic test for peptic ulcer
- Patients with suspected peptic ulcer should be evaluated for Helicobacter
pylori infection
- Serology (past or present infection),
urea breath testing (current infection),
and stool tests
n  NONULCER DYSPEPSIA
- associated with bloating and, unlike peptic ulcer, tends not to remit and
recur
- marginal relief on acid-reducing, prokinetic, or anti- Helicobacter therapy
Ø  Schatzki’s ring causes episodic dysphagia for
solids, typically at the beginning of a meal;
Ø  oropharyngeal motor disorders typically present
with difficulty initiating deglutition ( transfer
dysphagia )
Ø  nasal reflux or coughing with swallowing; and
achalasia may cause nocturnal regurgitation of
undigested food.
*** mechanical obstruction is suspected--- endoscopy is a useful initial
diagnostic test, since it permits immediate biopsy and/or dilatation of
strictures, masses, or rings.
ANEMIA AND OCCULT BLOOD IN THE STOOL
l  Iron-deficiency anemia
Ø  poor iron absorption (as in celiac sprue)
Ø  chronic blood loss
Intestinal bleeding --- in men and postmenopausal women with iron-
deficiency anemia
--- colonoscopy is indicated even in the absence of
detectable occult blood in the stool.
---30% will have large colonic polyps,
10% will have colorectal cancer,
few additional patients will have colonic vascular lesions.

Ø  source of blood loss is not found in
the colon,
Ø upper gastrointestinal endoscopy
should be considered
Ø  if no lesion is found, duodenal
biopsies should be obtained to exclude
sprue.
Ø  Small bowel evaluation with capsule
endoscopy or deep enteroscopy may
be appropriate if both EGD and
colonoscopy are unrevealing
n  COLORECTAL CANCER SCREENING
- majority of colon cancers develop from preexisting colonic adenomas,
and colorectal cancer
- prevented by the detection and removal of adenomatous polyps
- increased risk for colorectal cancer:
→ inflammatory bowel disease, a history of colorectal polyps or cancer,
family members with adenomatous polyps or cancer,
or certain familial cancer syndromes.

Virtual colonoscopy (VC)

Capsule endoscopy images of a is a radiologic technique
mildly scalloped jejunal that images the colon with
fold (left) and an ileal tumor (right) in CT following rectal
a patient with celiac sprue insufflation of the colonic
lumen.

Scalloped duodenal folds

in a patient with celiac familial adenomatous polyposis
syndrome
sprue

COLORECTAL CANCER SCREENING

OPEN-ACCESS ENDOSCOPY (OAE) Ø  Patients with particular conditions and undergoing certain procedures
should be prescribed prophylactic antibiotics prior to endoscopy
- is defined as the performance of endoscopic procedures requested by
referring physicians w/ out a prior clinic consultation.
- increasingly used in US and Europest Ø  patients taking anticoagulants and/or antiplatelet drugs may require
adjustment of these agents before endoscopy based on the procedure
- commonly offered for EGD, colonoscopy, and flexible sigmoidoscopy
risk for bleeding and condition risk for a thromboembolic event
- indications for endoscopy are clear-cut and appropriate,
the procedural risks are low, decreases
cost Ø  Common indications for open-access EGD: dyspepsia resistant to a trial
and the patient understands what to expect of appropriate therapy; dysphagia; gastrointestinal bleeding; and
persistent anorexia or early satiety.

Ø  Open-access colonoscopy is often requested:

Ø  Patients referred for open-access endoscopy should have a recent
history, physical examination, and medication review.
Ø  Patients with unstable cardiovascular or respiratory conditions should not
be referred directly for open-access endoscopy.
- in men or postmenopausal women with iron-deficiency anemia,
- in patients over age 50 with occult blood in the stool,
- in patients with a previous history of colorectal adenomatous polyps
or cancer,
- for colorectal cancer screening.
Ø  When patients are referred for open-access colonoscopy:
→ the primary care provider may need to choose a colonic preparation.

→ Commonly used oral preparations include: polyethylene glycol

lavage solution, with or without citric acid.

→ A “split-dose” regimen improves the quality of colonic preparation.

→ Sodium phosphate purgatives may cause fluid and electrolyte
abnormalities and renal toxicity, especially in patients with renal failure or
congestive heart failure and those over 70 years of age.