Fundamentals of GIT GIT: Gall Bladder 2021 - 2022

Gall Bladder
● Gall Stones formation:
o Normal bile salt/cholesterol ratio 25/1
● Investigation:
o If it ↓ to 13/1 precipitation occur. Laboratory Radiological
1. CBC: 1. Ultra-Sonography:
o leukocytosis o 1st Investigation
(Acute calicular cholecystitis o Visualize:
& Ascending cholangitis) − Both: radio-lucent & Radio-opaque stones (Gall
2. Blood culture: (for E. coli for bladder < CBD)
Ascending cholangitis) − Intrahepatic Biliary dilatation
3. Liver Function Test. − Hepatic & Extrahepatic Lesions
✓ Cholestatic pattern: o N.B: In CCC there is shrunken & fibrosed Gall Bladder.
(Obstructive Jaundice)
− Confirm dilatation of CBD > 7 mm diameter usually
o ↑ Conjugated Bilirubin > without distension of GB
60% of total Bilirubin
o ↑ Alkaline Phosphatase 2. ERCP:
● Types: o Diagnostic: Visualize stone in lower end of CBD. (less
o ↑ GGT activity
● Cholesterol ● Bile pigment ● Mixed (most common) sensitive in detecting stones in gall bladder)
o Normal or mild elevated
● Presentation & Complication: AST o Therapeutic:
o Complication: ascending cholangitis + Pancreatitis
● ● Next Diagram ●●
4. Urine and stool analysis: 3. MRCP: (non-invasive maneuver) = no dyes
● Treatment: o Dark color urine, pale o More sensitive & specific than ERCP by 90%
1. Asymptomatic Gall Bladder: white stool (obstructive 4. Plain X ray:
▪ Wait & See Except: Jaundice) o Only 10 % of Gallstones are radio- opaque
– Diabetic patient – Congenital hemolytic anemia 5. PTC:
– patient undergoing bariatric surgery – Young fit patient o Diagnostic: Diagnose high obstruction of bile duct
2. Symptomatic Gall bladder: o Complications: Biliary peritonitis – Bleeding may occur
▪ Cholecystectomy
3. Treatment of Complications: • Conservative ttt:
A. Acute Cholecystectomy Semi setting position – Stop oral
▪ Patient with mass: Conservative ttt then cholecystectomy. feeding – Anti spasmodic – Sedative
▪ Patient without mass: urgent cholecystectomy. – Antibiotic – Monitoring Vital signs
B. Acute pancreatitis
D. Ascending Cholangitis: Urgent treatment:
▪ Conservative ttt
▪ Broad spectrum Antibiotic (ceftazidime + Gentamicin + metronidazole)
C. Obstructive Jaundice: (Preoperative?)
▪ Treatment of obstruction: Early decompression of Biliary System by Endoscopic "ERCP"
▪ ERCP & sphincterotomy remove with Dormia Basket
or Radiological stenting “PTC”
▪ If Succeeded: laparoscopic cholecystectomy 1
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 Fundamentals of GIT GIT: Gall Bladder 2021 - 2022

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 Fundamentals of GIT GIT 2021 - 2022

Acute Pancreatitis
● Definition: Autodigestion of pancreas.
Clinical picture Investigations
● Causes: I get Smashed ▪ Male patient 50-60 Y, History of the cause → ▪ For diagnosis:
• Idiopathic • Steroid Major Symptoms & Minor Signs 1. Serum amylase
• Gall Stone • Mumps ▪ Symptoms: (Non-specific, N 100-300 somogi unit/dl)
1. Sever epigastric pain radiating to back, ↓ in a. Pancreatitis< 1000somogi unit /dl
(50%)Comments • Autoimmune
prayer position. b. ↓ after 5 days → measure urinalyses
• Ethanol (35%) • Scorpion venom 2. Reflex Nausea & Repeated vomiting. c. Serum lipase & Iso-amylase:
• Trauma • Hyperlipidemia ▪ Signs: More specific √√√
(ERCP & surgery)
• Hypercalcemia 1. General: 2. CT Scan: accurate for localizing
• Drugs: thiazide – OCP - ▪ Fever, Tachycardia 3. X-Ray: Colon cut-off sign + sentinel loop
▪ Signs of MOF (Shock – cyanosis - jaundice) ileus
Azathioprine
● Pathology: 2. Local: ▪ For cause: Abdominal U/S
▪ Inspection: ▪ For Complications: CBC, ABG, KFT, LFT,
o Cullen Sign: Umbilical ecchymosis FBS & Serum Ca.
o Grey turner sign: Ecchymosis in flanks Treatment (Conservative)
1. Resuscitation, Monitoring
Complications
2. Analgesics (morphine), Antibiotic
▪ Systemic: 3. NPO, NG suction (IV Somatostatin, aprotinin)
4. Respiratory support, Ventilation
5. Re-assessment by ERCP
6. Surgical ttt: only if indicated & ttt of the
cause.
Bad Prognosis (Ranson’s Criteria)
On admission 48 h
▪ Local: • Glucose < 200 mg/dl • Hct < 10%
▪ Pancreatic (Chronic itis – Cyst - Abscess) • WBCs < 16.000 / μl • PO2 > 60 mmHg
• Age < 55 Y • BUN < 5 mg/dl
● Definition: Chronic inflammatory condition with irreversible damage to the exocrine then the endocrine tissue of the pancreas. • • Base deficit
Pancreatitis

AST < 250 IU/L

● Etiology: like acute pancreatitis but: Chronic alcoholism is the commonest cause then Gall Stone.
Chronic

• LDH < 350 IU/L • S. Ca > 8mg/dl

● Clinical picture: Triad of: 1. Recurrent abdominal Pain: Post prandial abdominal pain 2. DM 3. Steatorrhea malabsorption
● Investigation: Like acute pancreatitis. But Fecal pancreatic elastase > 100 (MCQ)
● Treatment ●Stop alcohol ● Pancreatic enzyme replacement: taken as enteric coated tablets. ● Symptomatic treatment
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Peptic Ulcer
● Definition: Ulceration of mucosa which exposed to acid peptic juice distending to ● Clinical Picture: Dyspepsia (Pain related to food)
muscularis mucosa.
● Sites: DU GU
1. Duodenum (Proximal Part) Young – fit Old patient
Type of patient
2. Stomach (Lesser curvature) Well Healthy Thin – underweight
3. Jejunum (After gastrojejunostomy) Dyspepsia Dyspepsia
4. Esophagus − Epigastric pain related − Epigastric pain
5. Meckel’s diverticulum to meal − Immediately after
(contain ectopic gastric tissue) − 2-3 H after meal meal
Symptoms
● Cells of stomach − Mainly evening
o Parietal cells (chief cells) → Secrete HCl: Nausea & Vomiting Nausea & vomiting
Body weight Loss of weight
a. G: Gastrin. b. Ach: Vagus C. H2: Histamine
Hematemesis
o Gastric cells → Gastrin
Signs Pointing pain
o Peptic cells → pepsinogen
o Bleeding √√ Same +
● Factors Affecting HCl Secretion: Complications o Perforation o Cancer
Vagus omatostatin o Pyloric obstruction (MALT Lymphoma)
Gastrin S ecretine ● Investigation: Diagnosis
Histamine cholesestokinin Ulcer H – Pylori
● Etiology: • Upper GIT Endoscopy √√√ • Non-invasive:
● Mechanism of NSAIDs & o Diagnosis & follow up. o Anti-body titer in Blood
Acid  Mucosal Barrier
H. pylori??? o Biopsy (to Exclude Malignancy) − Positive result does not mean
1. H. Pylori active Infection
2. N. SAIDs • Normally • Barium Meal (Site & deformity) − Present after in Blood after ttt
3. Smoking − PGI2 → - - GA secretion & eradication of organism
• Investigation of complications:
Aggravating
Factors S 4. Stress
5. Spirits
− PGE2 & PGF2 → VD →
 Protective mucosa
o Bleeding: CBC, Occult Blood
o Ag in Stool
− Most sensitive test
o Perforation: Chest X-Ray
• SO, − Positive = active Infection
6. Reflux of Bile Zollinger: ↑ Gastrin & CT Scan
− NSAID →  cox →
o o Breath test: 14C Urea
7. Diseases: − 4 Weeks after ttt to confirm
Cirrhosis COPD – CRF -- PG formation →
eradication of H. pylori.
Zollinger Ellison’s $  GA &  Mucosa
• Invasive
(Multiple ulcers distal to duodenal bulb)
− Endoscopy with biopsy
(Rapid urease test: change in color)
− Culture & sensitivity
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Peptic Ulcer
● Treatment: Diet – Medical – Surgical – Complications
1. Diet: Treatment of Barret’s
− Avoid S. - Frequent small meal. - Sleeping in semi setting.
Esophagus
2. Medical:
Ulcer H. Pylori
Endoscopy for follow up
 Acid  Mucosa • Course: 6 Weeks
o Antacid (Mild cases) o Prostaglandin • Triple
▪ Al & Mg Hydroxide analog 2 Weeks followed by PPI for 4W • No dysplasia
o H2 Blocker: 4-8 W ▪ Misoprostol − PPI: Omeprazole 20 mg twice
▪ Ranitidine: o Sucralfate ✓ Continue follow up endoscopy
daily
150 mg twice OR − Clarithromycin 500 mg twice ✓ Treatment of GERD
300 mg at bedtime daily
o PPI: 4-6 W
− Amoxicillin 1gm /daily
• Dysplasia
▪ Omeprazole
OR Metronidazole 500 mg/day ✓ Endoscopic mucosal resection
20 mg/day
• Quadruple (2 Weeks)
If failed of above Or Clarithromycin ✓ Radiofrequency ablation
resistance ✓ Cryotherapy
− Omeprazole, 20 mg PO bid
− Tetracycline, 500 mg PO qid ✓ Laser ablation
− Bismuth 525 mg PO qid ✓ Surgery: in high grade dysphagia
− Metronidazole, 500 mg PO qid
▪ Avoid NSAIDs: Use selective Cox-2 Inhibitor As Lomoxicam OR NSAID + PPI
3. Surgical:
• Operation: Parietal cell vagotomy
• Indication:
− Refractory cases - Recurrent bleeding- Perforation - Pyloric obstruction - Malignancy
4. Complication:
• Bleeding: Ranitidine Or omeprazole - Endoscopic injection of adrenaline - Blood transfusion
• Perforation: IV fluid – analgesic – antibiotic then surgery
• Pyloric Obstruction: Surgery

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GERD
● Definition: ● Complications: Atypical +
Reflux of gastric contents into the esophagus affect patient 1. Erosion & ulceration of mucosa
(Symptoms & signs)
2. Bleeding
● Etiology & Risk factors:
3. Peptic stricture causing dysphagia
A) XX Lower esophageal sphincter XX Esophageal Clearance
4. Aspiration of gastric content (aspiration pneumonia)
Sliding Hiatus Hernia
5. Barret’s esophagus (In long standing case)
1.
S Smoking – Spirits - Caffe
Scleroderma o Columnar metaplasia
2. ‫ ام‬Obese + Drugs (theophylline – Ca antagonist)
o ↑↑ risk of adenocarcinoma 25 times

3. ‫ ↓ طفل‬Gastrin → ↓ Tone of cardia ● Investigation:

Clinical Diagnosis
B) XX Gastric Emptying Dx (Typical)
• Gastroparesis (DM) + Pyloric stenosis Complications (Atypical)
(esophagitis – Hiatus hernia)
1. 24 h PH Monitoring: (Gold standard) 1. Chest X-ray: Bad chest
● Clinical Picture:
2. Manometry
Atypical 2. CBC: anemia (IDA)
Typical
3. Upper GI Endoscopy
1. Bad chest o Only in:
Heart Burn
• Laryngeal manifestation:
✓ Alarming symptoms
− Retrosternal. − Persistent cough (Dysphagia & weight loss)
− Burning. − Morning hoarseness ✓ Symptoms persistent despite
− Mimic angina. • Pulmonary manifestation
Triad Tx for 4-8 Ws
30 – 90 min − Nocturnal asthma
4. Barium Swallow
after meal − Pneumonitis
− Pulmonary fibrosis ● Treatment: As P.U
Regurgitation Dysphagia 2. Anemia 1. Diet: Avoid Risk factor
• D.t bleeding from Ulcer
2. Posture therapy:
• These Symptoms o Raising the head at the bed time
o ↑ by Posture (lying flat bending) o Avoid lying down after eating.
o ↓ by Standing & Antacid o Remain upright at least 2h after eating.
3. Drug therapy: ○ ↓Gastric acidity ○ ↑ Esophagus peristalsis: domperidone
4. Surgical & Endoscopic therapy: Nissen Fundoplication in resistant cases

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Achalasia Of Cardia
Definition Investigations
Functional disorder of oesophagus characterised
A.Diagnosis
by failure of relaxation cardiac of sphincter during
swallowing & weak primary peristalsis above it 1. Barium swallow 2. Esophageal manometry
leading to functional obstruction & progressive - earley >> delayed evacuation. - Pressure in high pressure zone>25 mmHq.
dilatation of the oesophagus. - Late >> sigmoid esophagus.
- lower end >> parrot beak 3. Esophagoscopy+biopsy
appearance. - to detect carcinoma.
Etiology Clinical Picturer - absence of air in fundus of the 4. Plain x ray chest
Unknown may be due to: Type of patient: stomach. - Absence of gastric air bubbles.
degeneration of ganglia in Auerbach - more in 2nd to 4th decade.
plexus & vegal fibres. - Eq male = female.
B.Complications
CBC
Symptoms (DRRBP) Signs Late - anemia. - leukocytosis.
1. Dysphagia - General condition is better than
- Fluids > solid. cancer patient.
- Gradual onset, slowly progressive of - Bad nutrition, anemia.
long duration, intermittent.
Complications
2. Requiremdation 1. Aspiration pneumonia (bad chest).
- When lying down during night.
2. Malnutrition >> anaemia
3. Retrosternal pain (esophagitis) hypovitaminosis (bad general
condition).
4. Bad odour (halitosis)
3. Malignant changes:
5. Pulmonary symptoms - %5 after 20years.
- aspiration, wheezes. - discovered Late. Treatment

Differential Diagnosis 1. Surgery 2. Medical 3. Foreciable dilatation

oesophago-myotomy sphincterotomy by; by pneumatic
- From other causes of dysphagia mainly from carcinoma
(modified hellers CCBs, botulinum toxin pressure ballon.
- Old male ,rapidly progressive dysphagia of short duration, more to solid.
myotomy). or nitrate.

Old age: Young age:

Medical Tx. 1. Pneumatic dilatation
2. Surgery. (if 1 failed)

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Irritable Bowel Syndrome

Definition C.Negative screening investigation
Functional (normal investigation - no structural lesion) disorder of Colon ● Fecal biomarkers:
characterised by abdominal pain + changes in defecation maybe constipation - Fecal calprodectin < 50.
predominant, diarrhoea predominant or alternating. - Somatostatin (↑anxiety).
- Visceral hypersensitivity pain precipitation.
- Sigmoid muscularis propia thickness.
● Stool examination.
● CBC ESR , Blood glucose, thyroid fx test,fecal fat.
● Colonoscopy.
Etiology
Unknown, combination of :
1. Altered bowel motility. Treatment malignancy ‫ ﻻ ﻳﻘﻠﺐ‬،‫ ﻓﻬﻤﻪ اﻟﻤﺮض‬،‫اﺳﻤﻊ ﻣﻨﻪ ﻛﻮﻳﺲ‬
2. Altered bowel sensation.
3. Psychological factors. 1. Reassurance, psychological support (doctor patient relationship).
2. Recommending dietary measure (life & diet modification).
Diagnosis - Simple sugar (diet low in FODMAPS) → Formen table + ↓lactose
Oligosaccharides
- ↑Fibers - ↓caffeine → ↓anxiety + ↓fructose
Diarrhoea
A.Positive ROME 14 Criteria - ↑Fluid - ↓Lequm → ↓bloating Mono
● Reccurant abdominal pain at least 3 days per month during the previous 3 Polyols
months in the preceding 6 months.
Associated with ≥ 2 of the following: ( FFFPPM)
- Change in stool frequency (>3 day or <3 week). 3. Psychological &symptomatic ttt.
- Change in stool from → hard, loose, watery. - Referal. - mid sedative.
- Relived by deficaition. - anti depressant. - tranquilizer
- Straining or incomplete evacuation (change in stool pattern).
- Bloating or feeling distension.
- Passage of mucus. Constipation Diarrhoea Pain

B.Absence Of Alarm Signs (Symptoms in constant with IBS) •↑Fibres, laxative. •anti diarrheal •antispasmodic.
•Cl channel activator. (Loperamide → non (Mebeverine)
- Age >45 y , acute, progressive, nocturnal symptoms.
•Serotonin receptors S2,4 specific in severe
- Bleeding anemia, bleeding per rectum.
agonists (R/zelmac diarrhoea cap/8hour).
- Cashexia.
,tegaserad). •Antibiotic ( like Rifaximin).
- Diarrhoea painless , steatorrhea.
•activate serotonin type - Non absorbable.
- Fever.
4 receptors in GIt. - Long acting → 550 mg
- Gluten intolerance.
•prokinetic agents. potid for 14 days.
- History of cancer Colon family.
•improve symptoms in
- IBD.
diarrhoeal perdominant in
IBS (Without constipation).

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Inflammatory Bowel Disease
ULCERATIVE COLITIS CROHNS DISEASE
Definition Chronic diarrhoea of Unknown etiology (multifactorial) resistant to treatment remission and
excerbation characterized by:
- Ulceration - Granuloma formation
Etiology - Unknown. - Immunological. - Genetics. - Psychological. - Infection (bacteria).
Incidence Female >male 4th, 5th decade. Equal.. 2nd, 4th decade.
Site - Begin of dentate line of anal canal extended - Most common → Terminal ileum.
proximal. - 2nd common → Colon then anal canal.
- May affect rectum procolitis up to whole colon - May affect any part of GIT (mouth → anal
rectum pancolitis. canal.
- Backwash ileitis. - LN ++
Micro - Inflammation superficial mucosal and - Non-caseating granuloma in submucosa, giant
submucosal. cells.
- Crypt abscess. (infected ulcer of mucosa) - Trans-Mural... whole thickness.
- Pseudo polyps. (Oedematous mucosa,
surrounded by ulcers, ↑↑↑precancerous, surgery.
Macro - Varies from mucosal oedema up to extensive - Characterised by granuloma formation.
ulceration. - Normal in between (skip lesion)
- Continues lesion. - COBBLESTONE appearance (multiple Fissure
withmucosal edema).
Clinical 1.Chronic diarrhoea
- Bloody, transmucus, Fecal urgency. - Watery malabsorption.
Picture 2.Abdominal pain
- Cramps in left iliac fossa. - ↑In RLQ ± mass.
3.Fever, weight loss
- Less. - More.
4.Oral ulcer
Complications •EXTRA-GIT
Skeletal:
- Perphiral arthritis.
- Sero negative spondyloarthropathy (ankylosing span).
- Osteoporosis.
Skin:
- Erythema nodosum (painful, red, SC nodule).
- Pyoderma gangrenosa (ulcerated lesion).
- Aphithous ulcer (ulcer oral cavity).
Eye:
- Uveitis, iridocyclitis, episcleritis.
Hepato billary
- Fatty liver.
- primary sclerosing cholangitis.
1ry billiary cirrhosis 2ry scelerosing cholangitis
Intra-hepatic Intra & extra hepatic
+ve AMA -ve AMA, +ve ANCA
xx Steroid Steroid
Hematological
- ↑Risk of venous, arterial thrombosis.
- AIHA.
Lung
- Serositis.
- ILD.
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Inflammatory Bowel Disease
ULCERATIVE COLITIS CROHNS DISEASE
Complications •GIT
- Toxic Megacolon. - Malabsorption → B12 deficiency.
- Malignancy (cancer: %3-2 after 10 years old of - Fistula to another loop , bladder, ...
pancolitis multicentric). - Fibrosis → stricture → intraspinal obstruction.
- Massive haemorrhage.
- Perianal suppuration
Investigation •LABORATORY
Exclude infection
- CBC: wbcs, anemia (iron, vitamin B12). - stool analysis, culture, Occult blood in stool.
Antibody panel (non-specific)
P ANCA
↑↑↑ ↑
ASCA
↑ ↑↑↑
faecal calprotectin
- > 200 Mg/g
•INSTRUMENTAL (COLONSCOPY, BIOBSY)
- macro, micro (CB4)
•IMAGING (BARIUM ENEMA/CT,CONTRAST)
- Pseudopolyp. - Ccobblestone appearance.
- Pipe stem appearance. (loss of haustration) - String sign of kantor.
- Skip lesion.
Treatment •GENERAL
- rest, Diet, (↑protein, vitamin, calories, fibers).
•SYMPTOMATIC
- Antidiarrheal, Antibiotic, Analgesic
•SPECIFIC
- According to true love criteria. - According to CDAI index.
mild-moderate mild-moderate
REMISSION - Oral ulcer:
- rectal 5ASA trimiclone acetate
- Upper git:
MAINTENANCE: biological
- no in first attack - Colon:
- if 2nd attack: rectal 5ASA for 2 Year Rectal 5ASA budesenoide
NB if relapse or left sigmoid: rectal + oral 5ASA Rectal oral 5ASA
NO RESPONSE: MAINTENANCE:
- immunosuppressant - Rectal 5ASA + Oral 5ASA + Budesonide
- biological
Severe Severe
- hospitalization - hospitalization
- Oral rectal - IV steroid
- Steroid - immunosuppressant
- immunosuppressant - biological
- biological - surgical
SURGICAL (Failure of medical - Complications):
- Pan-procto-colotomy
COMPLICATION (Fulminant)
- IV fluid, antibiotic, steroid cyclosporine ± blood
transfusion ± Heparin
NB • indication of biological
- Steroid: - inresponsive - intolerance
- immunosuppression: - inresponsive -intolerance
- Upper git
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