Lecture 25 January 10th-gi

1DDX: LECTURE 25 – JANUARY 10TH 2007 GASTROINTESTINAL DISORDERS Page 1 • What would make us think that the patient has a GI disorder? See list on pg. 1. • • • • • • •

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Many of these are S/Sx of conditions that are nothing to do with the GI tract. Have to know how to differentiate. Other organs can produce referred pain to the abdomen: o Heart attack (especially with women) Ascites can be from GI source, but can also result from nutrient deficiency, portal hypertension, low protein levels in the blood (possibly kidney malfunction), metastatic cancers that move to the abdomen Nausea and vomiting: will be in MANY different condition: brain, heart, kidney problems. Weight gain/loss? Many different conditions. Tenesmus: urge to have a bowel movement, but only a small amount of stool produced (may not have anything to do with GI) Jaundice: may be from liver, but could have other sources Hemoptysis: spitting blood Hematemesis: vomiting blood. Could be produced by bleeding ulcers, esophageal varicies (d/t portal hypertension) Hematochezia: passing fresh blood from the rectum, with or without stool Melena: black, tarry stool: from upper GI bleed. Can also occur from lung condition where there is hemoptysis, patient swallows blood, ends up as melena.

Note RED FLAGS! (list in notes) • Progressive weight loss, night sweats, fevers: possible malignancy, especially in the elderly. However, cancers have been missed because these signs show up in younger patients as well: not limited to elderly. • Blood in stool (different from “blood from rectum”): blood is mixed into stool. • PUD=peptic ulcer disease. Esophageal problems are becoming more common d/t widespread use of antacids. UPPER GI BLEEDING • M/C than lower GI bleeding • Consider with history of alcohol abuse or cirrhosis, use of NSAIDs or any • DDX list: see list on page 1. • What is more dangerous? Duodenal or Gastric ulcer? Gastric, because it can lead to gastric cancer (75% become metastatic cancers). Complications of gastric ulcer are perforation, hemorrhage. Have to treat this patient as potential cancer patient. We can help to prevent this transformation. Page 2 • Lab tests: If the patient has excessive bleeding, have to consider a coagulation problem. • Check liver function: make sure there is no hepatic injury. • Abnormal bleeding, may result in serum electrolyte imbalance. ABDOMINAL PAIN • Different types: visceral, parietal, superficial abdominal wall pain, referred pain. • DDX list: (there are many more than those listed) Ectopic pregnancy? May also see hypotension, fainting, diarrhea, constipation, n/v. With ruptured ectopic pregnancy, patient can go into shock. Surgery is required. Lung pathology: can go undiagnosed for a long time, esp. if the pathology is on the lower lobes. This gives referred pain into abdomen. Familiar Mediterranean fever: Disease of unknown etiology. Find in residents of Mediterranian: presents with severe cramping abdominal pain. Often misdiagnosed as having appendicitis: similar signs, but in surgery, appendix is normal. Appendectomy may be performed anyway so that this is ruled out the next time that they present with abdominal pain! Pancreatitis: Character of pain is like a metal bar, in a straight line, right across the abdomen. Can also be diffuse, but usually presents in this way. To diagnose, need to do blood tests: amylase, lipase. Peritoneal inflammation can be from many sources: perforated ulcer, perforated appendix, PID (pelvic inflammatory disease), kidney pathologies (including kidney stones). If the abdomen is hard: sign of peritoneal involvement. Bowel obstruction, especially with ischemia. Rupture of abdominal aortic aneurysm: emergency: patient is bleeding into peritoneal cavity. Consider PREGNANCY! In rare cases, the woman doesn’t know that she is pregnant! • Extraperitoneal causes: Tabes dorsalis: Involvement (degeneration) of posterior columns of spinal cord with advanced form of syphilis. Lead poisoning: characterized by severe abdominal pain with no other symptoms. Uncommon in North America, but more common in other parts of the world. Patient intake: • History is important!!! Physical exam: not covered in detail, will be discussed in PCD. Page 3 Chart: abdominal pain Sudden pain: something has changed suddenly in the body: rupture. Eg. In babies: intussusception (telescoping of the small intestine that

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causes bowel obstruction: presents with abdominal pain with vomiting. May see bulging in abdominal wall.) Example patient: Acute/chronic diarrhea in women +45: nothing found in stool examination, no shock. Has had diarrhea for about 1 month. Always good to consider ovarian cancer! This is sometimes the only presenting symptom. Diarrhea is result of peritoneal irritation, and body is trying to clear toxic products from cancer. Digital rectal examination: has to be done. Might elicit some peritoneal irritation that the patient may not be able to feel. Soft abdomen in elderly patient: their peritoneum may not respond in the same way as a younger patient whose abdomen would be rigid as a result of peritoneal irritation.

DISEASES OF THE ESOPHAGUS • Dysphagia: difficulty swallowing. Only happens when lumen is narrowed to 13mm. Patients may have a pathology that doesn’t narrow the esophagus this much: won’t have dysphagia. • Most pathologies involve the lower esophageal sphincter. If it doesn’t close properly, reflux of stomach contents. • Antacids: ½ of population is on them. Hyper/hypochlorhydria (too much, too little acid in stomach) have the same symptoms! Patients with too little acid in stomach may be taking antacids. Increase in esophageal cancers with antacid use? • Underlying pathology is the sphincter. In patients with hypoacidity, increasing the stomach acid will train the esophageal sphincter to close over time. If the sphincter doesn’t work, acid will come back into esophagus regardless of acid level in stomach. • Stomach acid has pH of 1-2, esophagus has pH of 7. Acid reflux causes ulceration, perforation, GERD… Acid levels used to be CHECKED. Many people have HYPOacidity due to stress, etc. • We can do a lot for low acidity with naturopathic medicine. • See notes for factors that affect lower esophageal sphincter. Chest pain due to esophageal pathology:

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Can occur during swallowing, may present as throat pain, burning, sometimes in the ears as well.. May not feel it in esophagus at all. Spontaneous motor pain may look like angina.

Page 4 • Esophageal hyperalgesia: Pain in esophagus d/t ulcerative colitis: inflammation along entire GI tract. LES is fine, acid levels fine, but pain here. • Diffuse esophageal spasm: can’t pinpoint anything specific that produces this spasm. • • •

Pre-esophageal origin: something else is putting pressure on the esophagus, causing dysphagia. Obstruction Problem swallowing both solids/liquids? Motor dysfunction of esophagus. Rapid worsening of symptoms? Check for malignancy.

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Regurgitation: Food comes back into the mouth from the stomach or the esophagus. Can be diverticula (outpouching of esophagus, a small sac where food can get trapped and sit for days. Cyclic vomiting: nothing to do with pathology of esophagus.

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Obstructive disorders that will cause difficulty swallowing: • Very enlarged lymph nodes, lymphomas, lung cancer • Esophageal injuries: mainly in elderly. Have to swallow a lot of pills: swallow and they get stuck. Cause erosion of esophagus, local effects for medications that are intended to have a systemic effect. • For hiatal hernia: train stomach to drop. The “Heel Drop”: Take 8oz glass of warm water, drink, and then jump onto heels 20-30 times. Weight pulls stomach down, stimulates the lower esophageal sphincter to close. Has to be done on an empty stomach. Should be done again during the day on empty stomach. Page 5 • Food can get stuck in hiatal hernia! • Won’t be examined on fundoplication etc: just good to know what our patients may be going through. Gastro esophageal reflux disorder (GERD) • Persistent, non-productive cough. This may be the only symptom. Due to acid reflux. Patient inhales vapours, produces irritation of bronchi, produces cough. Can be very irritating for asthma patients. Asthma medication can cause GERD, malfunction of LES. • Whenever an endoscopy is done, a biopsy is required as well. • Manometry: measuring the pressure of the esophagus. If the pressure is low, the esophagus is too relaxed, isn’t pushing the food into stomach. If the pressure is too high, there will be a spasm, preventing proper movement of food. • Diagnostic procedures on page 5 will DDX between different pathologies. Page 6 • Nutcracker esophagus: Esophageal spasm occurring in co-ordinated manner. Can measure occurrence of spasms. Does not progress, unlike the diffuse esophageal spasm that worsens over time (DDX feature) • CT scan: more important if there is thickening of esophageal wall. Page 7 Not easy to DDX esophageal pathology because of the number of structures in the immediate area. Dysphagia DDXs: will talk about these in following lectures. CASE: 41-year-old woman with history of throat burning, ear pain, intermittent dysphagia. Presented to GP with these symptoms: diagnosed with chronic infection of throat. Months passed, continued testing, worsening of symptoms. At some point, mentioned that food was getting stuck behind sternum, in throat, started to have vomiting with blood.

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After a year, she was sent for an endoscopy. Delayed gastric emptying was observed (food in stomach from previous 24 hours: she had fasted for 18 hours before endoscopy, but food was still in stomach). Sometimes she vomits food from 3 days ago. Couldn’t see much in stomach d/t quantity of food. Subsequent endoscopy: observed severe esophagitis with delayed emptying. She also had asthma that would occur cyclically every 3-4 days. What was happening was that her stomach was emptying slowly over 3-4 day period. She was afraid to eat, wouldn’t eat much. As the stomach was emptying, acid would come back up and cause asthma. She was diagnosed with esophagitis D that is precancerous. It took a year to diagnose this because she presented with throat pain.

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