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Dr. Ajmal Hasan

MBBS, MD, DM (AIIMS, New Delhi)

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Dr. Ajmal Hasan

GI & Liver Symptoms

Jaundice

Abdomen pain

Gastrointestinal bleeding

Dysphagia

Diarrhoea & constipation

Dyspepsia

Intestinal Gas

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Jaundice

Jaundice is a symptom of liver disease, which manifest as yellowish discoloration of urine and eyes,
Diagnosis is confirmed by performing liver function test (blood test)

Causes of jaundice are 

Unconjugated hyperbilirubinemia

  • Hemolysis
  • Gilbert syndrome

Conjugated hyperbilirubinemia– is due to the liver diseases which can either be liver inflammation or  obstruction in biliary system of the liver

Liver inflammation

  • Hepatitis A
  • Hepatitis B
  • Hepatitis C
  • Hepatitis E
  • Alcoholic hepatitis
  • Wilson Disease (Excessive copper in the liver)
  • Hemochromatosis (Excessive iron in the liver)
  • Autoimmune hepatitis

Obstruction in the biliary system of liver

  • Stone in the common bile duct
  • Tumor of the gall bladder, pancreas, and CBD causing CBD obstruction
  • Worm in CBD
  • Enlarged lymph nodes compressing CBD

Workup

Following tests are done to know the cause of jaundice

  • LFT
  • Viral markers
  • USG Abdomen
  • CECT Abdomen and MRCP

Treatment

  • Treatment of jaundice depends upon the cause of jaundice and includes
  • Antiviral medication
  • Stopping alcohol
  • Steroids for autoimmune hepatitis
  • Copper and iron chelation for Wilson disease and hemochromatosis respectively
  • ERCP to remove the CBD stone or stent placement to bypass biliary obstruction due to tumor

Abdomen pain

Abdomen pain can be acute in onset and short in duration or maybe chronic of long duration

Common causes of acute abdomen pain are

  • Acute appendicitis
  • Cholecystitis due to gall bladder stones
  • Acute pancreatitis
  • Perforated peptic ulcer
  • Intestinal obstruction
  • Intestinal perforation
  • Mesenteric vascular ischemia
  • Diverticulitis
  • Renal and ureteric stones and pyelonephritis
  • Metabolic such as diabetic ketoacidosis, uremia, porphyria
  • Gynecological causes such as ectopic pregnancy, abortion, ovarian tumors

Causes of chronic pain abdomen are

  • Functional dyspepsia-Indigestion and bloating
  • Irritable bowel syndrome
  • Peptic ulcer disease
  • Ulceration in the small or large intestine
  • Chronic pancreatitis
  • Chronic cholecystitis
  • Abdomen tuberculosis
  • Inflammatory bowel disease (Ulcerative colitis and Crohn’s disease)
  • Fluid in peritoneal cavity due to tuberculosis, pancreatitis or malignancy
  • Tumor of stomach, intestine, liver, and pancreas

Treatment of pain depends upon the cause of pain, patients with acute severe pain abdomen should be immediately brought to medical attention so that the exact diagnosis can be established with proper investigations.
Chronic pain abdomen is mostly due to functional disorders like Functional dyspepsia and irritable bowel syndrome, which are diagnosed once the organic causes are ruled out with proper investigations.

Gastrointestinal bleeding

Bleeding from any part of the gastrointestinal tract from mouth to anus is defined as gastrointestinal bleeding, Patient may be having bleeding from the mouth (fresh red or coffee-colored altered blood) or in the stool. (which can be red, maroon, black).

Common causes of GI bleed are
Upper GI bleed

Esophageal source

  • Mallory Weiss tear
  • Esophageal varices
  • Esophagitis
  • Esophageal ulcer
  • Esophgageal cancer
  • Hiatus hernia with Cameron ulcers

Gastric source

  • Gastric ulcer
  • Gastric cancer
  • Gastric varix
  • Gastritis or gastropathy
  • Dieulafouy’s lesion
  • Gastric antral vascular ectasia

Duodenal source

  • Duodenal ulcer
  • Duodenal tumor

Lower GI bleed

Anal canal sources (Bright red blood)

  • Hemorrhoids
  • Fissure

Colonic source

  • Colonic ulcer- Infective or Inflammatory bowel disease
  • Colonic polyp or cancer
  • Angiodysplasia
  • Diverticular bleed

Small intestinal source

  • Angiodysplasias
  • Telangiectasias
  • Tumor of the small intestine
  • Meckel’s diverticulum
  • Ulcerations of the small intestine

Management of GI bleed depends upon magnitude and source of the bleed, patients with significant bleed should be admitted and resuscitated with blood and plasma expander infusion. Patients with chronic and small amounts of bleed can be investigated as an outpatient. Upper GI endoscopy and colonoscopy are the initial investigations for the cause of bleed, if these investigations are normal, the next line of investigations are CT enterography and CT angiography, capsule endoscopy and double-balloon enteroscopy.

Once the cause is established treatment depends upon the cause of bleed and includes ligation for esophageal varices, clip and APC application for ulcers and vascular lesions, and surgery for malignancies

Variceal band ligation Clip application for ulcer Glue application for fundal varix

Dysphagia

Dysphagia is difficulty in swallowing of food which occurs due to various esophageal disorders
Common causes of dysphagia are
  • Esophageal stricture
  • Peptic stricture
  • Esophageal cancer
  • Achalasia
  • Esophageal web
  • Extrinsic compression of compression by lymph nodes
Diagnosis
Following test are required for diagnosis
  • Endoscopy
  • Barium swallow
  • Esophageal manometry
  • CECT chest
Treatment depends upon the cause and includes
  • Endoscopy and dilatation for stricture
  • Stent placement for malignancy
  • Balloon dilatation and medications for Achalasia


Metal Stent placed for Esophageal cancer

Diarrhea & constipation

Diarrhea

Diarrhea is an increase in frequency or decrease inconsistency (liquid or semisolid) of stool
Diarrhea can be acute (less than 28 days) or chronic
Acute diarrhea is most infectious in origin and are self-limiting and are treated by oral and intravenous fluids, and use of antibiotics and antiparasitic agents in selected cases
Long-standing diarrhea is caused by diseases of the small and large intestine and pancreatic insufficiency
Small intestinal causes of diarrhea

  • Celiac disease
  • Tropical sprue
  • Giardiasis and other parasitic infections
  • Whipple disease
  • Small bowel tuberculosis
  • Small bowel Crohn's disease
  • Chronic variable immunodeficiency and other immune deficiencies
  • Small intestinal bacterial overgrowth

Large bowel causes of diarrhea

  • Ulcerative colitis
  • Crohn’s disease
  • Microscopic colitis
  • Colonic malignancies
  • Lymphoma
  • Radiation colitis
  • Ischemic colitis

Pancreatic disorders

  • Chronic pancreatitis
  • Cystic fibrosis

Other causes include excessive secretion due to various endocrinological causes
Diagnosis requires evaluation of stool, blood tests, endoscopy, colonoscopy and biopsies. Therapy is targeted at specific etiology.

Constipation

Constipation is a decrease in the frequency of stool (less than one stool in 3 days) or change form normal stool frequency for a particular individual

Common causes of constipation are

  • The slowness of bowel movement
  • Hypothyroidism
  • Diabetes mellitus
  • Hypercalcemia
  • Hypokalemia
  • The side effect of certain medications
  • Obstructing lesion in the colon such as large polyp or malignancy
  • Anal fissure

Evaluation requires blood testing and colonoscopy., and cross-sectional imaging and anal manometry

Treatment is targeted at specific etiology

Dyspepsia

Dyspepsia is a group of symptoms pertaining to the upper abdomens, such as

 

  • Postprandial fullness
  • Early satiety
  • Epigastric pain
  • Epigastric burning
  • Bloating in the upper abdomen
  • Nausea and vomiting
  • Belching

 

Most of the time, after investigations no organic cause is found in these cases and dyspepsia is labeled as functional dyspepsia.
Organic causes of dyspepsia are

 

  • Gastroesophageal reflux disease
  • Peptic ulcer disease
  • Gastric malignancy
  • Tuberculosis/sarcoidosis
  • Menetrier’s diseases
  • Parasitic infections
  • Diabetes mellitus
  • Scleroderma
  • Medications
  • Chronic pancreatitis and pancreatic malignancy
  • Hypothyroidism
  • Hyperparathyroidism
  • Myocardial ischemia

 

Functional dyspepsia
Functional dyspepsia is defined as postprandial fullness, early satiety, epigastric pain or burning in the absence of gastrointestinal, systemic or metabolic causes likely to cause these symptoms
Investigations
Young patients with dyspepsia and without alarming symptoms such as dysphagia, weight loss, anemia, bleeding can be given a trial of medication and should be investigated in case of persistent symptoms
Middle-aged or elderly patients with fresh onset symptoms or patients with alarming symptoms should be investigated
Following are investigation done in patients with dyspepsia

 

  • UGIE and H pylori testing
  • CBC/LFT/LFT
  • Thyroid function test
  • USG abdomen

 

Other investigation may be required depending on the clinical situation
Treatment
Prokinetic drugs, proton pump inhibitors, simethicone, antidepressant, and SSRI are used for the treatment of dyspepsia

Intestinal Gas

Excessive intestinal gas may be due to
  • Excessive swallowing during eating
  • Excessive production from undigested food
Symptoms of excessive gas are
  • Eructation
  • Excessive flatus
Treatment
Dietary restriction of
  • Legumes and raisins
  • Milk
  • Banana
  • Onion
  • Carrot
  • Potato
Medication
  • Simethicone
  • Probiotics
  • Antibiotics such as Rifaximin