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pankreatobilier
(Diseases and Abnormalities in the
Gastroenterological and Pancreatobiliary System)
Introduction
Syndrome of Dyspepsia
Defensive factors
Mucosal blood flow
Epithelial cell surface
Prostaglandin
Phospholipid/surfactan
Mucus
Bicarbonate
Motility
Mucosal impermeability to
H+ ion
Intracellular pH regulation
Growth factor
NUD:
1. ulcerlike: dominant epigastric pain, relieved by
antacids or food
2. dysmotility like: epigastric discomfort aggravated
by food or associated with early satiety, fullness,
nausea, retching, vomiting, or bloating.
3. nonspecific: symptoms does not fit the other
categories
Ulcer: the same with NUD
Pathophysiology of GERD
Spectrum Of Endoscopic
Findings with GERD
Normal esophagus
Grade 3 esophagitis
Grade 4 esophagitis
Barretts esophagus
MANAGEMENT of GERD
DEFINITION:
PUD Mucosal break gaster and duodenum,
diameter more than 0,5 cm.
Refractory ulcer duodenal ulcer 8 weeks
therapy ineffective or gastric ulcer lack response
to 12 weeks treatment.
PATHOGENESIS: Imbalance, aggressive factors
>>> defensive factors(see dyspepsia).
FINDINGS ON DIAGNOSTIC
TESTING of PUD
MANAGEMENT of PUD-1
Non pharmacological management:
- stomach diet,
- avoid/stop aggressive factors: stress etc.
Pharmacological management:
- H2 receptor antagonist.
- Proton pump inhibitors.
- Cytoprotective Agents: Sucralfate, Misoprostol,
Bismuth subsalicylate, Tephrenone and
Rebamipide
1.
1. If
PPI+Amoksisilin+Klaritromisin
2. PPI+Metronidazol+Klaritromisin
3. PPI+Metronidazol+Tetrasiklin (alergy to chlarithromisin)
DYSPHAGIA
DEFINITION:
- Dysphagia sensation of food being hindered in
its passage from the mouth to the stomach.
- Odynophagia pain on swallowing.
- Globus sensation perception of a lump,
tightness, or fullness in the throat that is
temporariloy relieved by swallowing.
CATEGORY: Dysphagia divided into:
1. Illnesses involving oral preparation, oral transfer,
or pharyngeal phases of swallowing
2. conditions involving dysfunction
of the
esophageal phase
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Oropharyngeal dysphagia
Neuromuscular diseases
Cerebrovascular accident
Parkinsons disease
Wilsons disease
Amyotrophic lateral sclerosis
Brain stem tumors
Bulbar poliomyelitis
Peripheral neuropathy
Myasthenia gravis
Muscular dystrophies
Polymyositis
Metabolic myopathy
Amyloidosis
Systemic lupus erythemathosus
Local mechanical lesions
Inflammation(pharyngitis, abscess, tuberculosis, radiation, syphilis)
Neoplasm
Congenital webs
Plummer-vinson syndrome
Extrinsic compression(thyromegaly, cervical spine hyperostosis, adenopathy)
Oropharyngealk resection
Upper esophageal sphincter(UES) disorders
Hypertensive UES
Hypotensive UES
Abnormal UES relaxation(cricopharyngeal achalasia, central nervous system, lymphoma,
Oculopharyngeal muscular dystrophy, cricopharyngeal bar, Zenkers diverticuum, familial
Dysautonomia)Esophageal dysphagia
Motility disorders
Achalasia
Scleroderma
Diffuse esophageal spasm
Nutcracker esophagus
Hypertensive lower esophageal sphincter
Nonspecific esophageal dysmotility
Other rheumatologic conditions
Chagas disease
Intrinsic mechanical lesions
Benign stricture(peptic, lye, radiation)
Schatzkis ring
Carcinoma
Esophageal webs
Esophageal diverticula
Benign tumors
Foreign bodies
Extrinsic mechanical lesions
Vascular compression
Mediastinal abnormalities
Cervical osteoarthritis
DIAGNOSIS of Dysphagia
Management of Dysphagia
ACHALASIA-1
ACHALASIA-2
UPPER GASTROINTESTINAL
BLEEDING(HEMATEMESIS-MELENA)
WORKUP/DIAGNOSIS of Hematemesis
Melena
Resuscitation
History
Physical examination
Upper gi endoscoopy
Scintigraphy and angiography: the rate of blood loss
must exceed 0.5 ml per minute.
Other radiographic studies: for aortoenteric fistula
abdominal computed tomographic or magnetic
resonance imaging studies
Blood Transfusion
Medications: PUD/gastritis: H2RA, or PPI; varices or portal
gastropathy: vasopressin / terlipressin / somatostatin or
octreotide . Angiodysplasia: intravenous or oral estrogens with
or without progesterone.
Therapeutic endoscopy: thermal and nonthermal methods.
Emergency upper endoscopy ; esophageal banding or
sclerotherapy.
Mechanical compression: ballon tamponade/SenstakenBlakemore tube or Linton-nachlas , then followed by
sclerotherapy or ligation.
Therapeutic angiography
Surgery:if endoscopy fails
LOWER GASTROINTESTINAL
BLEEDING
ETIOLOGY/CAUSES/DIFFERENTIAL DIAGNOSIS
LOWER GI BlEEDING
Diverticulosis
Angiodysplasias
Hemorrhoids
Anal fissures
Neoplasms
Inflammatory bowel disease
Ischemic colitis
Infectious colitis
Radiation induced colitis
Meckels diverticulum
Intussusception
Aortoenteric fistula
Solitary rectal ulcera
NSAID-induced cecal ulcers
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
DIAGNOSIS/WORKUP
MANAGEMENT LOWER GI
BLEEDING-1
Medications.
Therapeutic endoscopy.
Therapeutic angiography.
Surgery
ACUTE ABDOMEN
Gastrointestinal
Appendisitis
Perforated peptic ulcer
Intestinal ischemia
Diverticulitis
Inflammatory bowel disease
Meckels diverticulitis
Pancreaticobiliary tract, liver, spleen
Acute pancreatitis
Calculous cholecystitis
Acalculous cholecystitis
Acute cholangitis
Hepatic abscess
Ruptured hepatic tumor
Splenic rupture
Urinary tract
Renal/ureteral stone
Gynecologic
Ectopic pregnancy
Tuboovarian abscess
Ovarian torsion
Uterine rupture
Ruptured ovarian cyst or follicle
Retroperitoneum
Abdominal aortic aneurysm
Supradiaphragmatic
Pneumothorax
Pulmonary embolus
Acute pericarditis
Empyema
History:
Acute appendicitis: periumbilical pain, low-grade fever, anorexia
with/without vomiting followed by movement of the pain into the right
lower quadrant McBurneys point.
Constipation: obstructive conditions, inflammatory disorders produce
ileus.
Watery diarrhea: gastroenteritis,
Bloody diarrhea: infectious colitis, inflammatory bowel disease,
mesenterial ischemia.
Jaundice: hepatic and pancreaticobiliary disease, sepsis.
Urinary abnormality : urologic disease.
Physical examination:
Appendicitis acute: local peritonitis at McBurneys point, psoas sign(+).
Perforation: general/local peritonitis, disappear of liver percussion
dullness.
Bruits mesenteric thrombosis.
Ectopic pregnancyunilateral adnexal mass with blue cervical
discoloration.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003
Initial studies:
Blood testing: anemia, leukocytes, or leukopenia, serum
electrolytes, blood urea nitrogen, and creatinine,
pregnancy test,
Peritonitis abdominal radiographs(3 positions
abdominal xray)
Gas in the biliary tree fistula or cholangitis. Ileus
diffusely dilated loops of the small intestine & colon.
Free subdiaphragmatic air 75% patients with ulcer
perforation.
Decision to operate immediately
Imaging studies: CT-scan, ERCP/MRCP
Urgent surgery
Conservative management
DIARRHEA
CLASSIFICATION
DIAGNOSIS OF DIARRHEA-1
History:
MANAGEMENT OF DIARRHEA
Intravenous resuscitation
Agents for mild diarrhea: antidiarrheal, bismuth subsalicylate,
diphenoxylate, codeine.
Antibiotics for acute infectious diarrhea
Therapy for osmotic diarrhea: carbohydrate malabsorption
lactase deficiency or fructose or sorbitol intolerance dietary
modification, lactase supplements
Therapy of secretory diarrhea somatostatin analog(octreotide),
parenteral calcitonin, indomethacine.
Therapy for inflammatory diarrhea anti-inflammatory
drugs(aminosalicylate and corticosteroid. Refractory cases
azathioprine, 6mercaptourine, methotrexate.
Cholangitis
Pancreatitis
Diagnosis of Acute
Pancreatitis
Clinical Features: abdominal pain, vomiting
Elevation of plasma amylase - lipase recommendation grade A
3 or 4 x normal (must not always rely on this value)
Plain radiograph
Abdominal Ultrasonography: pancreatic swelling(25-50%
patients), CBD/gall bladder stones, dilatation of the CBD
Abdominal CT-scan(recommendation grade C)
Abdominal Magnetic Resonance Imaging(MRI)
CBD stones: ERCP & MRCP
Severity of Acute
pancreatitis
Lypase
Autodigestive
Pancreatic necrosis