44thth year Gastroenterology year Gastroenterology LecturesLectures

Abdominal painAbdominal painJaundiceJaundice

GI bleedingGI bleeding

Yasir M KhayyatMBcHB,FRCPC,FACP

Assistant Professor of Medicine

Objectives of approach to Objectives of approach to abdominal painabdominal pain

Recognize the appropriate analysis of abdominal pain and consistently apply it.

Understand the differential diagnosis of abdominal pain by location and patient setting.

Apply the necessary investigations pertinent to the presenting abdominal pain

Approach to abdominal pain

Clinical AssessmentClinical Assessment

Basic principles:Introduce yourselfKnow what system or disease type

you are evaluatingWrite downBe brief and focused

Abdominal Pain AnalysisAbdominal Pain Analysis

Differential Diagnosis of Abdominal Pain by siteDifferential Diagnosis of Abdominal Pain by site

Think also of non Abdominal organs

Heart LungsSpine

MetabolicAorta

Approach to Jaundice

Objectives of the approach to Objectives of the approach to JaundiceJaundiceRecognize the appropriate

analysis of clinical jaundice and consistently apply it.

Perform the physical examination necessary to elicit the diagnosis.

Prioritize the common causes of jaundice and apply it in investigations.

Yellow discoloration of the tissues caused by retention of bilirubin.( skin,sclera,mucosa)

Detected when serum bilirubin exceed 2.5-3 mg/100 ml.

Direct bilirubin undergoes postproduction processing in the liver ,this helps in differentiating between

Pre-hepaticHepaticPost-hepatic

Jaundice : definitionJaundice : definition

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History: Age Onset Duration :short hx of

malaise,anorexia and myalgia= viral Long hx weight loss ,anorexia =

carcinoma Pregnant females Noticed: by the Patient/Relative Progression Associated Symptoms: fever: cholangitis Abdominal pain: gall stones,

pancreatic carcinomaviral prodrome

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Past medical history: Hem-Liver,contact with febrile patient

Past surgical history: including post operative phase

Travel history Previous Drugs/Illict drugs,Alcohol

Previous GI Imaging or Lab works

Family history ( such as hemolytis disorders,wilson’s disease,Gilbert’s disease,alpha 1 antitrypsin defeciency ) 14

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Physical ExaminationPhysical Examination

Physical examination:

General appearance : Wasted/Weak

Vital Signs Hands : Yellow, Clubbing, vasculitic

lesions,SBE Face : Malnutrition,Icterus,Fetor

hepaticus Trunk : signs of CLD Abdomen : Ascites,signs of

CLD,Splenomegaly,masses LL : LL edema 16

Isolated Disorders of Bilirubin MetabolismIsolated Disorders of Bilirubin Metabolism Congugated hyperbilirubinemiaCongugated hyperbilirubinemia Uncongugated hyperbilirubinemia Uncongugated hyperbilirubinemiaLiver DiseaseLiver Disease Acute hepatocellular dysfunctionAcute hepatocellular dysfunction Chronic hepatocellular dysfunction Chronic hepatocellular dysfunction Hepatic disorders with prominent Hepatic disorders with prominent cholestasischolestasis Jaundice in pregnancy Jaundice in pregnancy Jaundice in the postoperative period Jaundice in the postoperative periodObstruction of the Bile DuctsObstruction of the Bile Ducts CholedocholithiasisCholedocholithiasis Diseases of the bile ducts Diseases of the bile ducts Extrinsic compression of the bile ducts Extrinsic compression of the bile ducts

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HemolysisViral hepatitisAlcoholic liver diseaseDrugsBile duct stonesPancreatic carcinomaLiver metastasis

Most Common causes of Most Common causes of JaundiceJaundice

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CBC : hemolysis ( Hb , Bilirubin ,LDH

LFT : AlK P, GGT

Hepatitis Virus serology : HBV ( HBsAg , HBeAg ) – HCV (HCV Ab ) – HAV ( IgM,IgG )

PBC ( AMA , IgM ) , PSC ( MRCP , ERCP )

Imaging Modalities : Abd US , MRI , MRCP

Jaundice Work upJaundice Work up

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Tests to determine specific Tests to determine specific etiologyetiology

Approach to

Gastrointestinal

Bleeding

Objectives of approach to GI Objectives of approach to GI bleeding bleeding Ask the appropriate history and

perform the physical examination necessary to safely stabilize the patient .

Emphasize the importance of hemodynamic stabilization prior to proceeding with the endoscopy.

Refer the patient with GI bleeding to Gastroenterologist at the right time and on stable condition.

Gastrointestinal bleedingGastrointestinal bleeding

Upper Gastrointestinal Bleeding

Lower Gastrointestinal bleeding

Obscure Gastrointestinal Bleeding

Melena: passage of blackTarry offensive stool due to Bleeding form the upper GIT proximal to ligmant ofTretiz ( > 100 ml).

Basic Mechanisms:1. Hyperacidity2. H pylori3. Vascular anomalies4. Autoimmune5. Malignancy Ligament

of Treitz

Management OutlineManagement Outline Airway Breathing Circulation Decide on Admission

Causes of UGIB ( Causes of UGIB ( Hematemesis/Melena)Hematemesis/Melena)

Endoscopic DiagnosisEndoscopic Diagnosis

Take home messageTake home messageAlways think of hemodynamic

stability ABCThen think to do H & PCommon things are commonCareful not to kill the patient and

know when to call for somebody helpCommon diseases are peptic ulcers,

liver disease, drug induced and malignancy.

Decide if you admit ( ward/ICU) or discharge.

Causes of Lower GI Causes of Lower GI BleedingBleeding

1- Anorectal Diseases :Hemorrhoids,Anal fissures

2- Infectious Gastroentritis mixed with blood

3- Colonic Diverticulosis4- Colonic neoplasms5- Vascular malformations:associated with

renal failure/aortic stenosis6-Inflammatory bowel disease.

Lower Gastrointestinal Lower Gastrointestinal BleedingBleedingHistory:Age,Onset,Progression,preceptating

factorsAssociated symptoms: poor appetite,

weight loss, abdominal pain, vomiting, constipation,diarrhea,Tenesmus,Straining.

Previous: similar episodes/Investigations/treatment performed.

Physical ExaminationPhysical ExaminationVital signs: HR,BPSigns of anemiaAbdomen:

contour,tenderness,guarding ( presence or absence)

DRE : bright red or dark blood.CVS,Resp systems

Lower GI bleedingLower GI bleedingABCIV lines,CBC,Blood group and cross

matching/Hold.IV colloids if hypotension/Blood if

anemia.Imaging : CT scan- Abdomen USRefer the pt to GastroenterologyColonoscopy: diagnostic and

therapeuticAngiography of the mesenteric vessels.

Obscure GI bleedingObscure GI bleedingEvidence of Bleeding/anemia

where investigations of the upper and lower GI tracts are unrevealing.

Need to exclude findings related to the GI tract by performing upper endoscopy and colonoscopy.

Causes of Obscure GI Causes of Obscure GI bleedingbleedingMalignancy: Small bowel

neoplasmInflammatory:Crohn’s enteritisVascular: Vascular malformationsMeckel’s diverticulumRadiation related enteritisSmall bowel ulcers ( NSAID

related )

Investigations of Obscure GI Investigations of Obscure GI bleedingbleedingRadiology:CT scan/MRI abdomen & PelvisRBC tagged scan Mickel’s scanEndoscopy:Double ballon EnteroscopyCapsule Endoscopy