git diseases: dr monem alshok 8 / 10 / 2017

GIT Diseases:

Dr Monem Alshok

8 / 10 / 2017

GIT Lectures First Term2017 - 2018

1. Anatomy , Physiology & Investigations

2. Diseases of the mouth & Oesophagus

3. Diseases of the stomach & duodenum

4. Diseases of small intestine

5. Diseaes of large intestine

6. Diseases of Pancreas

Introduction:

• Major cause of morbidity & mortality.

• 10% of GP consultations are for indigestion.

• ¼ of GP consultations for diarrhea.

• Infective diarrhea is a major cause of ill heath & death in developing countries.

• GIT is one of the most common sites for cancer.

• Major advances had occurred in the field of GE;

• PUD proved to be an infective condition due to HP & Nobel prize had been given recently to its discoverer, Marshal.

• Molecular events in the CRC development had been discovered & from this effort became successful in its prevention by NSAIDs.

• GIT endoscopy made diagnosis of GIT diseases very easy.

• Therapeutic endoscopy made it possible to replace surgery for many GIT conditions as GI bleeding, bilairy stone removal & stenting, palliative cancer stenting, polyp removal, PEG & endoscopic mucosal resection.

In GIT diseases

Dx

• History

• Examination

• Investigations

Causes

• Endocrinal?

• Drugs

• Metabolic

• Allergic & Immunological

• Vascular

• Mechanical

• Hereditary Congenital

Constipation• Drugs

• Endocrine( DM , Thyroid , Parathyroid ,Glucagonoma )

• Neurogenic ( DM , Multiple sclerosis , Parkinson , Spinal cord , )

• Psychological

• Metabolic (Hypercalcaemia Uraemia Hypokalaemia Porphyria

Amyloidosis Lead poisoning)

• Anal & Colonic

• Physiological ( old age & pregnancy ) Functional

Investigations

7

In order to reach a diagnosis for digestive

disorders,

1 . Thorough and accurate medical

history will be taken by physician , noting

the symptoms you have experienced and

any other pertinent information.

2 . A physical exam is also done to help

assess the problem more completely.

3 . Investigations

Physical exams:Examination n

PR

Diagnostic Procedures in GI Diseases

• The gastrointestinal system includes the GI tract and its associated glands

• Esophagus

• Stomach

• Small intestine

• Colon

• Liver & Biliary tree

• Pancreas


• The diagnostic tests can be divided into several categories:

• Structural tests

• Functional tests

• Microbiology & Tests for Helicobacter pylori

• Special blood tests( Serology , Chemistry )

• Special stool tests

• Histopathology tests


Structural Tests


Structural Tests

• Radiography including CT &

PET

• Ultrasonography

• Nuclear Isotope Scanning

• Magnetic Resonance Imaging

• Gastrointestinal Endoscopy

• Endoscopic Ultrasonography

EUS

Immaging 1 . Plain X Ray:

• Show gas within bowel for diagnosis of Int obst if there are dialated loops

or fluid levels in the erect position.

• Soft tissue of the liver, spleen& kidneys & calcifications in these organs,

pancrease,blood vessels, LNs,calculi.

• Chest XR in erect position show air under diaphragm in perforated

viscus.

Plain X – ray

Plain X ray

Contrast studies:

• Barium & double-cnotrast barium using air with

barium, will show filling defects, strictures, erosions

& ulcers & fistula and even motlity disorders if under

fluroscopy e . G. Achalasia .

• Barium sulphate is harmless inert ssubstance but may

accumulate proximal to obstruction and become more

solid . Colonoscopy may postpone several days after

barium study to obtain clear view. Water soluble

contrast is usually used during CT scan and MRI

examinations.

Tests of structure: Imaging• Contrast studies: uses & limitations.

Indications Major uses Limitations

Ba swallow:

Dysphagia,rfelux,chest

pain,motility disorder

Stricture,

HH,GERD,Achalasia.

Aspiration risk

Poor mucosal detail

No biopsy

Ba meal:

Dyspepsia,epigastric

pain,vomiting,anemia,pe

rforation.

DU,GU,Gastric

Ca,GOO,

Gastric emptying

disorder.

Low sensitivity for early

cancer.

No biopsy

No HP assessment.

Ba follow through:

Diarrhea,abd pain, Obst by

stricture

Malabsorption.

Chrons.

Time consuming.

Radiation exposure.

Ba enema

Abn bowel habit,Rectal

bleeding,anemia,abd

pain

Ca,

diverticuli,stricture,megac

olon.

Difficult in elderly.

incontinance.,

No biopsy.

Contrast

Ba meal

Ba follow through

NormalCaeliac

Ba enema

Tests of structure: Imaging• U/S,CT,MRI:Increasingly used for abd diseases,

noninvasive & offer detailed images of abd contents.

Indications Major uses Limitations

US: Masses,abscess,organs,ascites,bil

iary dilation,gall stones,guided

needle aspiration & biopsy.

Low sensitive for small ls.

Little functional info.

Operator dependent.

Gass & obesity interfer with it.

CT: Pancreatic dis,liver tumor

deposits, tumor staging,

vascular lesions.

Expensive,high radiation,

may underestimate stage of

cancers as esophagus.

MRI: Tumor

stage,MRCP,pelvic/perine

al, chrons fistula.

Time consuming.

Clusterphobia,role not

fully established,limited

availability.

US CT MRI

• These non-invasive investigations are commonly

used for diagnosis of many intraabdominal diseases

and can detect even very small lesions.

• US: Can detect abdominal masses and cysts,

tumours, abscesses, organomegaly, ascites,

biliary tract dilatation, gall stones and guides

needle aspiration and biopsy of lesion. It can not

detect small lesions and gases in bowel and

obesity may obscure lesions.

CT MRI

• CT scan: Assessment of pancreatic diseases,

hepatic tumors, tumor staging. Can detect small

lesions.

• MRI: Hepatic tumour staging, MRCP (magnetic

resonance cholangiopancreatography). It

indicated in perianal and pelvic disease and for

detection of Crohn’s fistula. Contra-indicated in

presence of metallic prosthesis and cardiac

pacemaker. It is expensive.

Tests of structure: endoscopy• Endoscpy: UGI, LGI, Enteroscopy, ERCP,EUS , Double

balloon endoscopy, capsule video endoscopy.

• Increasingly used for abd diseases, noninvasive & offer

detailed images of abd contents.


Functional Tests


Functional Tests

• Tests for motility

• 24 hour pH monitoring

• Tests for acid output

• Tests for malabsorption

• Tests for pancreatic function

Gastrointestinal Endoscopy


• Direct method to

examine and biopsy

the mucosal lining of

the gastrointestinal

tract

• Various accessories

are available to take

biopsies and provide

therapy


Types of Gastrointestinal Endoscopy


Types of Gastrointestinal Endoscopy

• Esophagogastroduodenoscopy (Upper GI Endoscopy)

• Small Bowel Enteroscopy (Jejunoscopy)

• Colonoscopy (Lower GI Endoscopy)

• Sigmoidoscopy

• Endoscopic Retrograde Cholangiopancreatogram (ERCP)

Upper Gastrointestinal Endoscopy

• Heartburn

• Dysphagia or odynophagia

• Hematemesis or melena

• Dyspepsia or upper abdominal pain

• Unexplained weight loss or anemia

• Evaluation of abnormal Barium meal X-ray

• Suspected malabsorption

• Control of bleeding

• Dilation of stricture

• Removal of foreign bodies

• Removal of polyps

• Tumor ablation

Diagnostic Indications Therapeutic Indications


Contraindications to Upper GI Endoscopy

• Uncooperative patient

• Hemodynamically unstable patient: Recnet AMI, Unstable angina or arrhythmia,Severe resp dis.

• Suspected perforation

• Severe RA of the cervical spine

• Severe shock.

• Atlanto axial sublaxation.

• These may be relative in experienced hands.

Examples of therapeutic techniques in endoscopy.


Normal Esophagus Normal Stomach Normal Duodenum

Duodenal UlcerGastric UlcerEsophagitis

Lower Gastrointestinal Endoscopy

• Chronic diarrhea

• Rectal bleeding

• Iron deficiency anemia

• Unexplained abdominal pain

• Constipation, change in bowel habits or stool caliber

• Unexplained weight loss

• Evaluation of abnormal Barium enema x-ray

• Personal or family history of colon cancer

• Personal history of IBD

• Control of bleeding

• Removal of polyps

• Tumor ablation

• Dilation of stricture

• Colonic decompression

• Reduction of sigmoid volvulus

Diagnostic Indications Therapeutic Indications


Contraindications to Lower GI Endoscopy

• Uncooperative patient

• Hemodynamically unstable patient

• Suspected perforation

• Suspected colonic obstruction

• Suspected diverticulitis

• Soon after a myocardial infarction


Normal Colon Colon Cancer

Colon Polyp and Polypectomy

Endoscopic Retrograde Cholangiopancreatogram

Indications


Indications

• Obstructive jaundice (benign or malignant)

• Ascending cholangitis

• Gallstone pancreatitis

• Unexplained jaundice or elevated LFT’s

• Bile duct injury or leak after cholecystectomy

• Chronic pancreatitis

• Pancreatic cancer

• Suspected Sphincter of Oddi dysfunction


Gallstone impacted at ampulla, sphincterotomy being done and stones removed


Pancreatic cancer with dilated bile duct and pancreatic duct (Double Duct sign)

Endoscopic Ultrasound

• The ultrasound probe is placed

at the tip of the endoscope

• Allows ultrasonography of

organs from a close distance

• Allows close evaluation of the

bowel wall

• Can be used to take fine needle

aspiration samples from

adjoining regions/organs

Endoscopic Ultrasound

A T3 Rectal Tumor on EUS

Capsule Endoscopy

Capsule Endoscopy

• Capsule endoscopy is intended for visualization of the small bowel mucosa

• It may be used as a tool in the detection of abnormalities of the small

bowel in adults and children from 10 years of age and up

Diagnostic Indications

Capsule Endoscopy

• Capsule endoscopy is contraindicated for use under the following

conditions:

– In patients with known or suspected gastrointestinal obstruction,

strictures, or fistulas based on the clinical picture or pre-procedure

testing and profile

– In patients with cardiac pacemakers or other implanted

electromedical devices

– In patients with swallowing disorders

Contraindications


Functional Tests


Functional Tests

• Tests for motility

• Tests for pH

• Tests for acid output

• Tests for malabsorption

• Tests for pancreatic function

Functional Tests in GI Diseases

Tests for motility


Tests for motility

• Esophageal Manometry

• 24 Hour pH Monitoring

• Anorectal Manometry


Indications for Esophageal Manometry

• Oropharyngeal dysphagia with normal structural studies

- Cricopharyngeal achalasia, Pharyngeo-UES dyscoordination

• Esophageal dysphagia with normal structural studies

- Primary esophageal body dysmotility e.g. Achalasia, Diffuse esophageal spasm, Nutcracker esophagus, Hypertensive LES, Collagen vascular disease, Amyloidosis, Hypothyroidism, etc.

• Noncardiac chest pain


Esophageal Manometry Tracings

Esophageal Manometry


24 Hour pH Monitoring

Indications

• Patients with non cardiac chest pain

• Refractory acid reflux symptoms: evaluate treatment efficacy

• Pre and post-operative evaluation of antireflux surgery

• Patients with atypical presentations of acid reflux (ENT, pulmonary)


24 Hour pH Monitoring


Anorectal Manometry

• Used in the clinical assessment of patients in whom a problem with defecation is suspected

• This technique is helpful in evaluating the anorectal sphincter mechanism

• Contraindicated in the presence of an anal fissure, since the resting anal pressure is abnormally high


Anorectal Manometry

Tests of structure: Biopsy• Obtained through endoscpy or percutanously & sent for histopath exam.

• Reasons for biopsy or cytological exams:

• Brash cytology of suspected malignant lesions.

• Histological assessment of mucosal abns.

• Diagnosis of infections( candida, HP,Giardia).

• Measure enzymes as disacharidases.

• Analysis of genetic mutations as oncogenes , tumor suppressor genes.

2.Tests of infection: Bacterial cultures• For identifying causes of diarrhea sp if acute or bloody.

• Causes of infective diarrhea:

• Viruses: Rota, adeno, entero, requires EM or viral cultures.

• Bacteria: Campylo jej, EC,Salmonella,clostridium difficile( ned toxine isolation).

• Protozoa: Giardia,ameba, cryptosporidium & moicrospora.


Tests for Malabsorption


Tests for Malabsorption

• Serum screening tests for malabsorption

S. Calcium, Albumin, Iron, Vitamin B12, Folate, Carotene, Prothrombin time

• Quantitative fecal fat determination

• D-xylose absorption test

• Small bowel biopsy

• Schilling test for Vitamin B12 absorption

• Hydrogen Breath Test for lactose intolerance


Liver Biopsy

• Liver biopsy is a diagnostic procedure used to obtain a small amount

of liver tissue which can be examined under a microscope to help

identify the cause or stage of liver disease

• The most common way a liver biopsy is obtained is by inserting a

needle into the liver percutaneously

• Other ways to biopsy the liver are transjugular, laparoscopic and

surgical

• In case of a localized lesion in the liver a US or CT guided biopsy is

performed

Biopsy and pathology:

1. study of duodenal and jejunal biopsy material for

diagnosis of celiac disease (mucosal abnormalities).

2. To diagnose lesions like: e. g. inflammatory bowel

disease (e.g. cryptic anbscess in UC and granuloma in

Crohn’s disease) and tumors.

3. Also used for diagnosis of infection like Giardiasis,

H. pylori and fungal infection.

4. Some time enzyme study is done from biopsy

material.

UC

Crypt Abscess


Tests for Helicobacter pylori



Non-invasive• C13 or C14 Urea Breath Test

• H. pylori IgG titer (serology)

• Stool antigene for H Pylori.

Invasive• Gastric mucosal biopsy

• Rapid Urease test



C13 or C14 Urea Breath Test



Mucosal Biopsy



Rapid Urease Test

• This test is based on the

urease enzyme present in the

H. pylori

• Urea is split into NH3 and

CO2

• The change in pH causes a

color change in the medium


Blood tests

• Liver function tests

(LFT’S)

• Hepatitis serology

• S. Amylase & Lipase

• Alfa-Feto Protein (AFP)

• Carcino-Embryonic

Antigen (CEA)

Stool tests

• Stool microscopy

• Stool ova & parasites

• Stool culture

• Stool C. difficile toxin

• Stool occult blood

Upper GIT Endoscopy

LGIT Endoscopy

git diseases: dr monem alshok 8 / 10 / 2017

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