GI

e-Mental Script

1
Contents
Clinical Manifestations
1 Dysphagia PCD 1 Harrison’s
2 UGIB GCD 1 Harrison’s
3 LGIB GCD 2 Harrison’s
4 Dyspepsia Lecture 1 Sleisenger
5 Constipation Lecture 2 Harrison’s
6 Chronic Diarrhea Lecture 2 Harrison’s

Disease Script
UGIB
Peptic Ulcer Disease GCD 1 Harrison’s
Gastric Cancer GCD 1 Harrison’s
LGIB
Colorectal CA GCD 2 Harrison’s
Chronic Diarrhea
Inflammatory Bowel Disease PCD 2 Harrison’s
Malabsorption Syndrome PCD 2 Harrison’s
Irritable Bowel Syndrome PCD 2 Harrison’s

2
CLINICAL MANIFESTATIONS
Approach to Diagnosis?

3
PCD 1

Dysphagia
Harrison’s pp.

ANATOMY & PHYSIOLOGY

Muscles Innervation Action/s

oropharynx striated

UES cricopharyngeus (CP) CN 10 opening during swallowing

inferior pharyngeal constrictor - CN 5, 7, 12
closing: (at rest)
proximal part of the cervical
esophagus - d/t inherent elastic properties
- contractions of CP
opening:
- cessation of vagal stimulation to CP
- simultaneous contraction of
suprahyoid & geniohyoid
proximal striated lower motor neurons peristalsis:
esophagus of CN 10 - sequential activation of the vagal
motor nucleus in the nucleus
ambiguus
distal smooth esophageal peristalsis:
esophagus myenteric plexus - medullary preganglionic neurons of
the nucleus vagus
LES right diaphragmatic crus relaxation:
- occurs on the onset of deglutition
inhibition until peristalsis is
complete
contraction: (at rest)
- d/t excitatory ganglionic stimulation
and intrinsic myogenic tone

Oropharyngeal dysphagia

Pathology poor bolus formation & control

Clinical drooling
Manifestations difficulty swallowing
food retention in pharynx
d/t poor tongue/pharyngeal propulsion or
obstruction of the UES)

Causes Iatrogenic* Muscular Iatrogenic – surgery & radiation (esp. in head & neck CA)
Neurologic* Infectious Neurogenic – from CVA, PD, amyotrophic lateral sclerosis
Structural* Metabolic – *major source of morbidity related to
aspiration & malnutrition
 Zenker’s diverticulum
 Cricopharyngeal bar lateralization of pharyngeal dysphagia
 Neoplasia = structural/ neurogenic lesion selectively targeting
ipsilateral brainstem nuclei since medullary nuclei
directly innervate the oropharynx
Diagnosis Functional brain imaging Structural
: asymmetry in the cortical representation of pharynx  Zenker’s diverticulum
= dysphagia d/t unilateral cortical CVA - regurgitation of food debris
- aspiration
Rapid-sequence fluoroscopy - halitosis
: asymmetry in the cortical representation of pharynx - stenosis of CP → diminished opening of UES →
= dysphagia d/t unilateral cortical CVA increased hypopharyngeal pressure during
swallowing … Killian’s dehiscence
 Cricopharyngeal bar

 Neoplasia

Esophageal dysphagia

Pathology Esophagus: 2x3 cm lumen

Clinical In GERD patients without stricture *altered esophageal sensation, reduced esophageal mural
Manifestations Achalasia: absent peristalsis + failure of deglutive LES distensibility
relaxation

Causes when solid food is narrowed to <1.3 cm

Diagnosis

4
GCD 1

UGIB

5
GCD 2

LGIB

6
Lec 1

Dyspepsia
“sinisikmura”, “kinakabag”, “nabubunsol”, mabigat ang tiyan”, “impatso”, “di natunawan”
Sleisenger pp. ?-190
DYSPEPSIA

Epidemiology - exact prevalence: unknown

- annual prevalence worldwide:
bhjbk
Definition & Clinical
See Table 1-1 (Rome IV Criteria for Functional Dyspepsia)
Presentations

Approach See Figure 1-2 (Algorithm for the management

Alarm Symptoms - ???  : demographic data, nature & frequency, chronicity, relat
-
 Laboratory Tests
 Factors to consider in work-up:
-
History & PE - esp. comorbidities, drugs

Factors to consider  Fear of missing ……

 Presence of alarm
 cost
Laboratory Tests must depend on clinical data based on Hx & PE
 CCCC -

ORGANIC DYSPEPSIA
High Risk  ≥50 – 60 yrs old 
 NSAID use
 Alarm symptoms
Management Low Risk for organic dyspepsia: High Risk for organic dyspepsia 
1. Test for H. pylori then treat. prompt Endoscopy
2. Empiric anti-sec drug: PPI
Prokinetic Drug
3. Endoscopy followed by
targeted medical treatment
FUNCTIONAL DYSPEPSIA
Pathophysiology  impaired gastric accommodation (40%)  impaired gastric accommodation

 delayed gastric emptying (20-50%)  delayed gastric emptying

 visceral hypersensitivity  visceral hypersensitivity

 duodenal hypersensitivity  duodenal hypersensitivity

 small intestinal hypersensitivity  small intestinal hypersensitivity

 CNS dysfunction  CNS dysfunction

Pathogenic  Genetic predisposition  Genetic predisposition

Factors
 Infection (H. pylori, Salmonella)  Infection
- H. pylori (associated with organic dyspepsia)
 Psychosocial factors - Salmonella
 Psychosocial factors
Management (Based from ACG): 
PHARMACOLOGIC TREATMENT
 PPI – OD x 8 weeks
 H. pylori eradication therapy
2 antibiotics + PPI (double dose for 14 days)
 Prokinetic agents (very low quality evidence)
 TCAs (low quality evidence)
 Other Drugs
Simethicone
Buspirone
Acotiamide
NK receptor antagonist
K opiod receptor agonist
*No role for complementa & alternative medicine
NON-PHARMACOLOGIC TREATMENT
 Lifestyle & Dietarty
 ….


7
Lec 1: DYSPEPSIA

Figure 1-1. Schematic representation of the classification of uninvestigated dyspepsia,

functional dyspepsia (FD), and subtypes of functional dyspepsia according to the Rome IV criteria

Table 1-1. Rome IV Criteria for Functional Dyspepsia, Postprandial Distress Syndrome, and Epigastric Pain Syndrome,
Rome IV Criteria
Criteria fulfilled for the previous 3 months
with symptom onset at least 6 months prior to diagnosis
functional ≥1 of these: organic dyspepsia (no criteria but see causes)
dyspepsia Bothersome postprandial fullness
Bothersome early satiation
Bothersome epigastric pain
Bothersome epigastric burning
No evidence of structural disease (including at upper
GI endoscopy -EGD) that is likely to explain the
symptoms
PDS ≥1 of these at least 3 days a week: EPS ≥1 of these at least 1 day a week:
Bothersome postprandial fullness Bothersome postprandial fullness
Bothersome early satiation Bothersome early satiation
No evidence of structural disease (including at EGD) No evidence of structural disease (including at EGD)
Supportive Criteria: Supportive Criteria:
Postprandial epigastric pain or burning, epigastric Pain may be induced by ingestion of a meal, relieved
bloating, excessive belching, and nausea can also by ingestion of a meal, or may occur while fasting
be present
Postprandial epigastric bloating, belching, and
Vomiting warrants consideration of another disorder nausea can also be present
Heartburn is not a symptom of dyspepsia but often Persistent vomiting likely suggests another disorder
may coexist with PDS
Heartburn is not a symptom of dyspepsia but may
Symptoms that are relieved by evacuation of feces or often coexist with EPS
gas should generally not be considered part of the
The pain does not fulfill criteria for biliary pain
dyspepsia symptom complex
Symptoms that are relieved by evacuation of feces or
Other individual digestive symptoms or groups of
gas generally should not be considered part of the
symptoms (e.g., from GERD or IBS) may coexist
dyspepsia symptom complex
with PDS
Other digestive symptoms (such as GERD and IBS)
may coexist with EPS

8
Table 1-2. Organic Causes of Dyspepsia
ORGANIC DYSPEPSIA: Causes
Luminal GI Tract Medications Pancreaticobiliary Disorders Systemic Conditions
Chronic gastric volvulus Acarbose Biliary pain: cholelithiasis, Adrenal insufficiency
Chronic gastric or intestinal Aspirin, other NSAIDs (including choledocholithiasis, SOD Diabetes mellitus
ischemia COX-2 selective agents) Chronic pancreatitis Heart failure
Food intolerance Colchicine Pancreatic neoplasms Hyperparathyroidism
Gastric infections (CMV, fungus, Digitalis preparations Intra-abdominal malignancy
tuberculosis, syphilis) Estrogens Myocardial ischemia
Gastric or esophageal neoplasms Ethanol Pregnancy
Gastroesophageal reflux Glucocorticoids Renal insufficiency
Gastroparesis (diabetes mellitus, Iron, potassium chloride Thyroid disease
postvagotomy, scleroderma, Levodopa
chronic intestinal pseudo- Narcotics
obstruction, postviral, idiopathic) Niacin, gemfibrozil
IBS Nitrates
Infiltrative gastric disorders Orlistat
(Ménétrier disease, Crohn Quinidine
disease, eosinophilic Sildenafil
gastroenteritis, sarcoidosis, Theophylline
amyloidosis)
Parasites (Giardia lamblia,
Strongyloides stercoralisrom)
PUD

Figure 1-2. Algorithm for the management of patients with dyspepsia. <insert reference>

9
Lec 2

Constipation
Harrison’s pp. 268 - 270
Sleisenger pp. 250-295

CONSTIPATION (normal-t 65%, slow-t 5%*, defecatory/rectal DO)

Definition ACG: unsatisfactory defecation - infrequent and/or difficult passage of

stool
-
Rome IV (Functional Constipation)
*Functional Constipation vs. IBS-C
Bristol Stool Chart
Epidemiology Prevalence

Risk Factors &  Advanced age  Stress & stressful events

Pathophysiological  Female gender …. (self-reporting  Genetic factors
factors influence)  …
 Use of
Approach See Figure 1-2 (Algorithm for the management

Alarm Symptoms  Change in bowel habits  : demographic data, nature & frequency, chronicity, relat
 Unexplained IDA
 Recent sudden onset of sysmptoms

History  Acute or chronic

 Diet
 Surgery
 Abuse
 Comorbids
 Medications – antihypertensives, Analgesics….

PE  GS: facies, sacral dimpling
 Palpation
 Neuro
 Rectal
Diagnostic Tests must depend on clinical data based on Hx & PE

10
Treatment Treat if secondart
Non-Pharmacologic:
Reassurance
Lifestyle change
Psycho
Pah
Pharmacologic:
Bulk forming Laxatives
Emollient Laxatives
Saline Laxatives
Saline Cathartics
Hyperosmotic Laxatives (pediatric)
Castor oil (unpleasant)
Lactulose (best place to start)
Sorbitol
Stimulant Laxatives
Stimulant Laxatives (Senna)
5HT4 (Prucalopride)
Polyethylene Glycol (one of the best, needs 4L)
Cl Channel Activator
Guanylate cyclase-c (Linacloide)

Biofeedback (for defecatory Dos)

11
Lec 2: CONSTIPATION

Anatomy & Colonic Transit Time

Physiology Mean 34-35 hrs
Upper limit72 hour
Normal stool weight 250g
Types of Colonic Motor Patterns
 Non-Propagating Motor Pattern (predominant)
micing
Short duration
Long duration
-taenia coli
 Propagating Motor Pattern (high-amplitude)
 Rectal Motor Complexes
Colonic Reflex
COlocolonic Reflex
Gastrocolic Reflex
Orthocolic Reflex
NTK: peritoneointestina, renoinstestinal, vesico

Defecation

12
 PCD 2

Chronic Diarrhea
Harrison’s pp. 263-

CHRONIC DIARRHEA

Definition diarrhea lasting >4 weeks

increased frequency
stool weight >200g/day

Approach See Figure 1-2 (Algorithm for the management

Alarm Symptoms   : demographic data, nature & frequency, chronicity, relat

-
History & PE - esp. comorbidities, drugs

Factors to consider  Fear of missing ……

 Presence of alarm
 cost
Laboratory Tests must depend on clinical data based on Hx & PE
 CCCC -

Mechanism Clinical Features Causes

SECRETORY derangements in fluid & electrolyte transport - watery, large-volume fecal outputs Medications
- typically painless Bowel Resection
- persists with fasting
Mucosal Disease
Entero

OSMOTIC

STEATORRHEAL

INFLAMMATORY

DYSMOTILITY

FACTITIAL

IATROGENIC

1
Etiology derangements in fluid and electrolyte transport across the enterocolonic 
mucosa
Clinical Features - Because there is no malabsorbed solute,
Stool osmolality is accounted
Why is DRE as an overall screening limited?
 ~50% of patients with documented colorectal CAs have a (-) FOBT,
consistent with intermittent bleeding pattern of these tumors
 In random cohorts of asymptomatic persons, 2-4% have (+) FOBT
stools:
o colorectal CA is found only in <10% of these (+) individuals
∴ early detection of localized, superficial CAs in asymptomatic individuals
will increase surgical cure rate
Why Proctosigmoidoscopy?
60% of early lesions are located in the rectosigmoid
but the proportion of CAs arising in the rectum has been decreasing with
more corresponding increase in CAs arising in the proximal descending
colon

- 

2 DIARRHEA
Definition X 

3 DIARRHEA
Definition X 

4 DIARRHEA
Definition X 

13
14
DISEASE ILLNESS SCRIPT

15
Esophageal Cancer

16
GERD and Benign Peptic Ulcer

17
Peptic Ulcer Disease

18
Gastric Cancer

19
20
IBD
COLORECTAL CANCER

Epidemiology

Risk Factors/Causes

Clinical
Presentation

Pathology

Pathophysiology

Screening Indication/s: rationale for colorectal CA screening:

 (+) family hx in 1st degree relatives esp. if relative is afflicted <60 y.o.
 adults >40 years
Screening Strategies:
1. Digital Rectal Exam*
- limited overall screening modality for colorectal CA due to
proximal migration of colorectal tumors
2. Stool Testing: FOBT*
- also limited
- if positive, routinely undergo further medical evaluation
3. Endoscopy: Flexible sigmoidoscopy and/or Colonoscopy
- uncomfortable and expensive but justifiable
- associated with small risk of significant complications
(improved prognosis and prolonged survival)
 Protoscopy/Proctosigmoidoscopy
- visualizes the lower end of the colon and rectum
 Flexible Sigmoidoscopy
- visualizes the distal half of the large bowel (distal left colon
and rectum)
- requires only an enema as preparation that can be
performed by non-specialty physicians compared to other
colonoscopic procedures that requires cathartic preparation
performed only by trained specialists
 Colonoscopy:
- less sensitive than FS for screening the proximal than the
distal (perhaps d/t technical considerations or because of
greater frequency of serrated “flat” polyps in the right colon
which are more difficult to identify)
- superior to double-contrast barium enema
- higher sensitivity of detecting villous or dysplastic adenomas
or cancers than the strategy of using FOBT & flexible
sigmoidoscopy
Recommendations:
American Cancer Society and the
National Comprehensive Cancer Network:
asymptomatic individuals aged 50 above with NO personal or
family history of polyps & colorectal CA
 annual FOBT + flexible sigmoidoscopy every 5 years
or
 colonoscopy every 10 years + flexible sigmoidoscopy
every 5 years
removal of adenomatous polyps – prevents colorectal CA
∴ early detection of localized, superficial CAs in asymptomatic individuals
will increase surgical cure rate
DRE - also a screening test for prostate CA in men
- component of pelvic exam in women
- inexpensive maneuver for detection of mass in the rectum
FOBT
Why is DRE as an overall screening limited?
 ~50% of patients with documented colorectal CAs have a (-) FOBT,
consistent with intermittent bleeding pattern of these tumors
 In random cohorts of asymptomatic persons, 2-4% have (+) FOBT
stools:
o colorectal CA is found only in <10% of these (+) individuals
∴ early detection of localized, superficial CAs in asymptomatic individuals
will increase surgical cure rate
Why Proctosigmoidoscopy?
60% of early lesions are located in the rectosigmoid
but the proportion of CAs arising in the rectum has been decreasing with
more corresponding increase in CAs arising in the proximal descending
colon
Other Screening Strategies but not really recommended::
 Stool Guiac Screening
- annual screening shows significant reduction in
mortality rate from colorectal CA
- but benefit emerged after >13 years of follow-up
making the benefit expensive to achieve because all
positive tests (mostly a false +) were followed by
colonoscopy
 Stool Testing: fecal DNA
 Air Contrast Barium Enema
- used before the advent of fiberoptic endoscopy
- cumbersome, inconvenient to patients
 Imaging: virtual colonography(e.g. CT)
- equivalent sensitivity with colonoscopy
- does not require degree of level of expertise as
fiberoptic endoscopy
- requires the same cathartic preparation
- diagnostic but not therapeutic (because pxs with
suspicious findings will still undergo subsequent
endoscopic procedure for polypectomy or biopsy
- less sensitive compared to endoscopy

Diagnosis & Staging Biopsy

 Benign GU - found distal to the j(x) bw the antrum and the acid
secretory mucosa
 NSAID-related GUs - foveolar hyperplasia, edema of the lamina
propria, and epithelial regeneration in the absence of H. pylori

21
  Duodenal Ulcer
- common in the 1st portion of duodenum (95%), with ~90%
located within 3 cm of the pylorus
- ≤1cm in diameter (giant ulcer 3-6 cm)
Sharply demarcated sometimes reaching the muscularis
propria
- base: consists of a zone of eosinophilic necrosis with
surrounding fibrosis
- rare to be malignant
Treatment

Prognosis

Surveillance

22
Malabsorption Syndrome
COLORECTAL CANCER

Epidemiology

Risk Factors/Causes

Clinical
Presentation

Pathology

Pathophysiology

Screening Indication/s: rationale for colorectal CA screening:

 (+) family hx in 1st degree relatives esp. if relative is afflicted <60 y.o.
 adults >40 years
Screening Strategies:
4. Digital Rectal Exam*
- limited overall screening modality for colorectal CA due to
proximal migration of colorectal tumors
5. Stool Testing: FOBT*
- also limited
- if positive, routinely undergo further medical evaluation
6. Endoscopy: Flexible sigmoidoscopy and/or Colonoscopy
- uncomfortable and expensive but justifiable
- associated with small risk of significant complications
(improved prognosis and prolonged survival)
 Protoscopy/Proctosigmoidoscopy
- visualizes the lower end of the colon and rectum
 Flexible Sigmoidoscopy
- visualizes the distal half of the large bowel (distal left colon
and rectum)
- requires only an enema as preparation that can be
performed by non-specialty physicians compared to other
colonoscopic procedures that requires cathartic preparation
performed only by trained specialists
 Colonoscopy:
- less sensitive than FS for screening the proximal than the
distal (perhaps d/t technical considerations or because of
greater frequency of serrated “flat” polyps in the right colon
which are more difficult to identify)
- superior to double-contrast barium enema
- higher sensitivity of detecting villous or dysplastic adenomas
or cancers than the strategy of using FOBT & flexible
sigmoidoscopy
Recommendations:
American Cancer Society and the
National Comprehensive Cancer Network:
asymptomatic individuals aged 50 above with NO personal or
family history of polyps & colorectal CA
 annual FOBT + flexible sigmoidoscopy every 5 years
or
 colonoscopy every 10 years + flexible sigmoidoscopy
every 5 years
removal of adenomatous polyps – prevents colorectal CA
∴ early detection of localized, superficial CAs in asymptomatic individuals
will increase surgical cure rate
DRE - also a screening test for prostate CA in men
- component of pelvic exam in women
- inexpensive maneuver for detection of mass in the rectum
FOBT
Why is DRE as an overall screening limited?
 ~50% of patients with documented colorectal CAs have a (-) FOBT,
consistent with intermittent bleeding pattern of these tumors
 In random cohorts of asymptomatic persons, 2-4% have (+) FOBT
stools:
o colorectal CA is found only in <10% of these (+) individuals
∴ early detection of localized, superficial CAs in asymptomatic individuals
will increase surgical cure rate
Why Proctosigmoidoscopy?
60% of early lesions are located in the rectosigmoid
but the proportion of CAs arising in the rectum has been decreasing with
more corresponding increase in CAs arising in the proximal descending
colon
Other Screening Strategies but not really recommended::
 Stool Guiac Screening
- annual screening shows significant reduction in
mortality rate from colorectal CA
- but benefit emerged after >13 years of follow-up
making the benefit expensive to achieve because all
positive tests (mostly a false +) were followed by
colonoscopy
 Stool Testing: fecal DNA
 Air Contrast Barium Enema
- used before the advent of fiberoptic endoscopy
- cumbersome, inconvenient to patients
 Imaging: virtual colonography(e.g. CT)
- equivalent sensitivity with colonoscopy
- does not require degree of level of expertise as
fiberoptic endoscopy
- requires the same cathartic preparation
- diagnostic but not therapeutic (because pxs with
suspicious findings will still undergo subsequent
endoscopic procedure for polypectomy or biopsy
- less sensitive compared to endoscopy

Diagnosis & Staging Biopsy

 Benign GU - found distal to the j(x) bw the antrum and the acid
secretory mucosa
 NSAID-related GUs - foveolar hyperplasia, edema of the lamina
propria, and epithelial regeneration in the absence of H. pylori

23
  Duodenal Ulcer
- common in the 1st portion of duodenum (95%), with ~90%
located within 3 cm of the pylorus
- ≤1cm in diameter (giant ulcer 3-6 cm)
Sharply demarcated sometimes reaching the muscularis
propria
- base: consists of a zone of eosinophilic necrosis with
surrounding fibrosis
- rare to be malignant
Treatment

Prognosis

Surveillance

24
Irritable Bowel Syndrome
IBS

Definition abdominal pain or discomfort and altered bowel habits in the absence
of detectable structural abnormalities

Epidemiology - female
-

Diagnosis Rome IV Criteria for IBS

Recurrent abdominal pain ~1 day/ week in the last 3 months
+ >2 of the following criteria:
related to defecation
association with a △ frequency of stool
association with a △ form/appearance of stool
Supportive Criteria:
Postprandial epigastric pain or burning, epigastric bloating,
excessive belching, and nausea can also be present
Vomiting warrants consideration of another disorder
Heartburn is not a symptom of dyspepsia but often may coexist
with PDS
Symptoms that are relieved by evacuation of feces or gas should
generally not be considered part of the dyspepsia symptom
complex
Other individual digestive symptoms or groups of symptoms
(e.g., from GERD or IBS) may coexist with PDS

Pathology - ng

Pathophysiology

Screening Indication/s: rationale for colorectal CA screening:

 (+) family hx in 1st degree relatives esp. if relative is afflicted <60 y.o. removal of adenomatous polyps – prevents colorectal CA
∴ early detection of localized, superficial CAs in asymptomatic individuals
 adults >40 years will increase surgical cure rate
DRE - also a screening test for prostate CA in men
Screening Strategies: - component of pelvic exam in women
7. Digital Rectal Exam* - inexpensive maneuver for detection of mass in the rectum
- limited overall screening modality for colorectal CA due to FOBT
proximal migration of colorectal tumors Why is DRE as an overall screening limited?
8. Stool Testing: FOBT*  ~50% of patients with documented colorectal CAs have a (-) FOBT,
consistent with intermittent bleeding pattern of these tumors
- also limited
 In random cohorts of asymptomatic persons, 2-4% have (+) FOBT
- if positive, routinely undergo further medical evaluation stools:
9. Endoscopy: Flexible sigmoidoscopy and/or Colonoscopy o colorectal CA is found only in <10% of these (+) individuals
- uncomfortable and expensive but justifiable ∴ early detection of localized, superficial CAs in asymptomatic individuals
- associated with small risk of significant complications will increase surgical cure rate
(improved prognosis and prolonged survival) Why Proctosigmoidoscopy?
60% of early lesions are located in the rectosigmoid
 Protoscopy/Proctosigmoidoscopy
but the proportion of CAs arising in the rectum has been decreasing with
- visualizes the lower end of the colon and rectum more corresponding increase in CAs arising in the proximal descending
 Flexible Sigmoidoscopy colon
- visualizes the distal half of the large bowel (distal left colon
and rectum)
- requires only an enema as preparation that can be
performed by non-specialty physicians compared to other
colonoscopic procedures that requires cathartic preparation
performed only by trained specialists
 Colonoscopy:
- less sensitive than FS for screening the proximal than the
distal (perhaps d/t technical considerations or because of
greater frequency of serrated “flat” polyps in the right colon
which are more difficult to identify)
- superior to double-contrast barium enema
- higher sensitivity of detecting villous or dysplastic adenomas
or cancers than the strategy of using FOBT & flexible
sigmoidoscopy

25
 Recommendations:
American Cancer Society and the
National Comprehensive Cancer Network:
asymptomatic individuals aged 50 above with NO personal or
family history of polyps & colorectal CA
 annual FOBT + flexible sigmoidoscopy every 5 years
or
 colonoscopy every 10 years + flexible sigmoidoscopy
every 5 years
Other Screening Strategies but not really recommended::
 Stool Guiac Screening
- annual screening shows significant reduction in
mortality rate from colorectal CA
- but benefit emerged after >13 years of follow-up
making the benefit expensive to achieve because all
positive tests (mostly a false +) were followed by
colonoscopy
 Stool Testing: fecal DNA
 Air Contrast Barium Enema
- used before the advent of fiberoptic endoscopy
- cumbersome, inconvenient to patients
 Imaging: virtual colonography(e.g. CT)
- equivalent sensitivity with colonoscopy
- does not require degree of level of expertise as
fiberoptic endoscopy
- requires the same cathartic preparation
- diagnostic but not therapeutic (because pxs with
suspicious findings will still undergo subsequent
endoscopic procedure for polypectomy or biopsy
- less sensitive compared to endoscopy

Diagnosis & Staging Biopsy

 Benign GU - found distal to the j(x) bw the antrum and the acid
secretory mucosa
 NSAID-related GUs - foveolar hyperplasia, edema of the lamina
propria, and epithelial regeneration in the absence of H. pylori
 Duodenal Ulcer
- common in the 1st portion of duodenum (95%), with ~90%
located within 3 cm of the pylorus
- ≤1cm in diameter (giant ulcer 3-6 cm)
Sharply demarcated sometimes reaching the muscularis
propria
- base: consists of a zone of eosinophilic necrosis with
surrounding fibrosis
- rare to be malignant
Treatment

Prognosis

Surveillance

26
Colorectal Cancer
COLORECTAL CANCER

Epidemiology

Risk Factors/Causes

Clinical
Presentation

Pathology

Pathophysiology

Screening Indication/s: rationale for colorectal CA screening:

 (+) family hx in 1st degree relatives esp. if relative is afflicted <60 y.o.
 adults >40 years
Screening Strategies:
10. Digital Rectal Exam*
- limited overall screening modality for colorectal CA due to
proximal migration of colorectal tumors
11. Stool Testing: FOBT*
- also limited
- if positive, routinely undergo further medical evaluation
12. Endoscopy: Flexible sigmoidoscopy and/or Colonoscopy
- uncomfortable and expensive but justifiable
- associated with small risk of significant complications
(improved prognosis and prolonged survival)
 Protoscopy/Proctosigmoidoscopy
- visualizes the lower end of the colon and rectum
 Flexible Sigmoidoscopy
- visualizes the distal half of the large bowel (distal left colon
and rectum)
- requires only an enema as preparation that can be
performed by non-specialty physicians compared to other
colonoscopic procedures that requires cathartic preparation
performed only by trained specialists
 Colonoscopy:
- less sensitive than FS for screening the proximal than the
distal (perhaps d/t technical considerations or because of
greater frequency of serrated “flat” polyps in the right colon
which are more difficult to identify)
- superior to double-contrast barium enema
- higher sensitivity of detecting villous or dysplastic adenomas
or cancers than the strategy of using FOBT & flexible
sigmoidoscopy
Recommendations:
American Cancer Society and the
National Comprehensive Cancer Network:
asymptomatic individuals aged 50 above with NO personal or
family history of polyps & colorectal CA
 annual FOBT + flexible sigmoidoscopy every 5 years
or
 colonoscopy every 10 years + flexible sigmoidoscopy
every 5 years
removal of adenomatous polyps – prevents colorectal CA
∴ early detection of localized, superficial CAs in asymptomatic individuals
will increase surgical cure rate
DRE - also a screening test for prostate CA in men
- component of pelvic exam in women
- inexpensive maneuver for detection of mass in the rectum
FOBT
Why is DRE as an overall screening limited?
 ~50% of patients with documented colorectal CAs have a (-) FOBT,
consistent with intermittent bleeding pattern of these tumors
 In random cohorts of asymptomatic persons, 2-4% have (+) FOBT
stools:
o colorectal CA is found only in <10% of these (+) individuals
∴ early detection of localized, superficial CAs in asymptomatic individuals
will increase surgical cure rate
Why Proctosigmoidoscopy?
60% of early lesions are located in the rectosigmoid
but the proportion of CAs arising in the rectum has been decreasing with
more corresponding increase in CAs arising in the proximal descending
colon
Other Screening Strategies but not really recommended::
 Stool Guiac Screening
- annual screening shows significant reduction in
mortality rate from colorectal CA
- but benefit emerged after >13 years of follow-up
making the benefit expensive to achieve because all
positive tests (mostly a false +) were followed by
colonoscopy
 Stool Testing: fecal DNA
 Air Contrast Barium Enema
- used before the advent of fiberoptic endoscopy
- cumbersome, inconvenient to patients
 Imaging: virtual colonography(e.g. CT)
- equivalent sensitivity with colonoscopy
- does not require degree of level of expertise as
fiberoptic endoscopy
- requires the same cathartic preparation
- diagnostic but not therapeutic (because pxs with
suspicious findings will still undergo subsequent
endoscopic procedure for polypectomy or biopsy
- less sensitive compared to endoscopy

Diagnosis & Staging Biopsy

 Benign GU - found distal to the j(x) bw the antrum and the acid
secretory mucosa
 NSAID-related GUs - foveolar hyperplasia, edema of the lamina
propria, and epithelial regeneration in the absence of H. pylori

27
  Duodenal Ulcer
- common in the 1st portion of duodenum (95%), with ~90%
located within 3 cm of the pylorus
- ≤1cm in diameter (giant ulcer 3-6 cm)
Sharply demarcated sometimes reaching the muscularis
propria
- base: consists of a zone of eosinophilic necrosis with
surrounding fibrosis
- rare to be malignant
Treatment

Prognosis

Surveillance

28
Disease Illness Script:

Disease

Secretory

COLORECTAL CANCER

Epidemiology

Risk Factors/Causes

Clinical
Presentation

Pathology

Pathophysiology

Screening Indication/s: rationale for colorectal CA screening:

 (+) family hx in 1st degree relatives esp. if relative is afflicted <60 y.o. removal of adenomatous polyps – prevents colorectal CA
∴ early detection of localized, superficial CAs in asymptomatic individuals
 adults >40 years will increase surgical cure rate
DRE - also a screening test for prostate CA in men
Screening Strategies: - component of pelvic exam in women
13. Digital Rectal Exam* - inexpensive maneuver for detection of mass in the rectum
- limited overall screening modality for colorectal CA due to FOBT
proximal migration of colorectal tumors Why is DRE as an overall screening limited?
14. Stool Testing: FOBT*  ~50% of patients with documented colorectal CAs have a (-) FOBT,
consistent with intermittent bleeding pattern of these tumors
- also limited
 In random cohorts of asymptomatic persons, 2-4% have (+) FOBT
- if positive, routinely undergo further medical evaluation stools:
15. Endoscopy: Flexible sigmoidoscopy and/or Colonoscopy o colorectal CA is found only in <10% of these (+) individuals
- uncomfortable and expensive but justifiable ∴ early detection of localized, superficial CAs in asymptomatic individuals
- associated with small risk of significant complications will increase surgical cure rate
(improved prognosis and prolonged survival) Why Proctosigmoidoscopy?
60% of early lesions are located in the rectosigmoid
 Protoscopy/Proctosigmoidoscopy
but the proportion of CAs arising in the rectum has been decreasing with
- visualizes the lower end of the colon and rectum more corresponding increase in CAs arising in the proximal descending
 Flexible Sigmoidoscopy colon
- visualizes the distal half of the large bowel (distal left colon
and rectum)
- requires only an enema as preparation that can be
performed by non-specialty physicians compared to other
colonoscopic procedures that requires cathartic preparation
performed only by trained specialists
 Colonoscopy:
- less sensitive than FS for screening the proximal than the
distal (perhaps d/t technical considerations or because of
greater frequency of serrated “flat” polyps in the right colon
which are more difficult to identify)
- superior to double-contrast barium enema
- higher sensitivity of detecting villous or dysplastic adenomas
or cancers than the strategy of using FOBT & flexible
sigmoidoscopy

29
 Recommendations:
American Cancer Society and the
National Comprehensive Cancer Network:
asymptomatic individuals aged 50 above with NO personal or
family history of polyps & colorectal CA
 annual FOBT + flexible sigmoidoscopy every 5 years
or
 colonoscopy every 10 years + flexible sigmoidoscopy
every 5 years
Other Screening Strategies but not really recommended::
 Stool Guiac Screening
- annual screening shows significant reduction in
mortality rate from colorectal CA
- but benefit emerged after >13 years of follow-up
making the benefit expensive to achieve because all
positive tests (mostly a false +) were followed by
colonoscopy
 Stool Testing: fecal DNA
 Air Contrast Barium Enema
- used before the advent of fiberoptic endoscopy
- cumbersome, inconvenient to patients
 Imaging: virtual colonography(e.g. CT)
- equivalent sensitivity with colonoscopy
- does not require degree of level of expertise as
fiberoptic endoscopy
- requires the same cathartic preparation
- diagnostic but not therapeutic (because pxs with
suspicious findings will still undergo subsequent
endoscopic procedure for polypectomy or biopsy
- less sensitive compared to endoscopy

Diagnosis & Staging Biopsy

 Benign GU - found distal to the j(x) bw the antrum and the acid
secretory mucosa
 NSAID-related GUs - foveolar hyperplasia, edema of the lamina
propria, and epithelial regeneration in the absence of H. pylori
 Duodenal Ulcer
- common in the 1st portion of duodenum (95%), with ~90%
located within 3 cm of the pylorus
- ≤1cm in diameter (giant ulcer 3-6 cm)
Sharply demarcated sometimes reaching the muscularis
propria
- base: consists of a zone of eosinophilic necrosis with
surrounding fibrosis
- rare to be malignant
Treatment

Prognosis

Surveillance

30