Gastroenterology& hepatology:Gastroenterology& hepatology:IntroductionIntroduction

GI Diseases:GI Diseases: Major cause of morbidity & mortality.Major cause of morbidity & mortality. 10% of GP consultations are for indigestion.10% of GP consultations are for indigestion. ¼ of GP consultations for diarrhea.¼ of GP consultations for diarrhea. Infective diarrhea is a major cause of ill heath & death in developing countries.Infective diarrhea is a major cause of ill heath & death in developing countries. GIT is one of the most common sites for cancer.GIT is one of the most common sites for cancer. Major advances had occurred in the field of GE;Major advances had occurred in the field of GE; PUD proved to be an infective condition due to HP & Nobel prize had been PUD proved to be an infective condition due to HP & Nobel prize had been

given recently to its discoverer, Marshal.given recently to its discoverer, Marshal. Molecular events in the CRC development had been discovered & from this Molecular events in the CRC development had been discovered & from this

effort became successful in its prevention by NSAIDs.effort became successful in its prevention by NSAIDs. GIT endoscopy made diagnosis of GIT diseases very easy.GIT endoscopy made diagnosis of GIT diseases very easy. Therapeutic endoscopy made it possible to replace surgery for many GIT Therapeutic endoscopy made it possible to replace surgery for many GIT

conditions as GI bleeding, bilairy stone removal & stenting, palliative cancer conditions as GI bleeding, bilairy stone removal & stenting, palliative cancer stenting, polyp removal, PEG & endoscopic mucosal resection. stenting, polyp removal, PEG & endoscopic mucosal resection.

Clinical exam in GIT:

GI symptoms:GI symptoms: Dysphagia: difficult swallowingDysphagia: difficult swallowing Odynophagia: painful swallowing.Odynophagia: painful swallowing. Aphagia: can not swallow.Aphagia: can not swallow. Heart burn.Heart burn. Non cardiac chest pain.Non cardiac chest pain. Regurgitation.Regurgitation. Aerophagia: eructation.Aerophagia: eructation. Hematemesis.Hematemesis. Melena.Melena. Hematochesia: fresh bleeding per rectum.Hematochesia: fresh bleeding per rectum. Dyspepsia: abnormal digestion.Dyspepsia: abnormal digestion. Anorexia.Anorexia. Flatulence.Flatulence. Alteration in bowel habits.Alteration in bowel habits. Bleeding per rectum.Bleeding per rectum. Abd pain.Abd pain.

GI Diseases: InvestigationsGI Diseases: Investigations Tests of structure.Tests of structure. Tests of infection.Tests of infection. Tests of function.Tests of function.

1.Tests of structure: Imaging1.Tests of structure: Imaging Plain radiograph:Plain radiograph: Show gas within bowel for diagnosis of Int obst if there are Show gas within bowel for diagnosis of Int obst if there are

dialated loops or fluid levels in the erect position.dialated loops or fluid levels in the erect position. Soft tissue of the liver, spleen& kidneys & calcifications in these Soft tissue of the liver, spleen& kidneys & calcifications in these

organs, pancrease,blood vessels, LNs,calculi.organs, pancrease,blood vessels, LNs,calculi. Chest XR in erect position show air under diaphragm in Chest XR in erect position show air under diaphragm in

perforated viscus.perforated viscus.

SBO

LBO

Supine Prone

Tests of structure:ImagingTests of structure:Imaging

Tests of structure: ImagingTests of structure: Imaging Contrast studies:Contrast studies: Barium & double-cnotrast barium using air with barium, will Barium & double-cnotrast barium using air with barium, will

show filling defects, strictures, erosions & ulcers & even motlity show filling defects, strictures, erosions & ulcers & even motlity disorders if under fluroscopy.disorders if under fluroscopy.

Tests of structure: ENDOSCOPYTests of structure: ENDOSCOPY

Tests of structure: Tests of structure: ENDOSCOPYENDOSCOPY

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

IndicationsIndications Major usesMajor uses LimitationsLimitationsBa swallow:Ba swallow:

Dysphagia,rfelux,chest Dysphagia,rfelux,chest pain,motility disorderpain,motility disorder

Stricture, Stricture, HH,GERD,Achalasia.HH,GERD,Achalasia.

Aspiration riskAspiration risk

Poor mucosal detailPoor mucosal detail

No biopsyNo biopsy

Ba meal:Ba meal:

Dyspepsia,epigastric Dyspepsia,epigastric pain,vomiting,anemia,pepain,vomiting,anemia,perforation.rforation.

DU,GU,Gastric DU,GU,Gastric Ca,GOO, Ca,GOO,

Gastric emptying Gastric emptying disorder.disorder.

Low sensitivity for Low sensitivity for early cancer.early cancer.

No biopsyNo biopsy

No HP assessment.No HP assessment.

Ba follow through:Ba follow through:

Diarrhea,abd pain, Obst by Diarrhea,abd pain, Obst by stricturestricture

Malabsorption.Malabsorption.

Chrons.Chrons.

Time consuming.Time consuming.

Radiation exposure.Radiation exposure.

Ba enemaBa enema

Abn bowel habit,Rectal Abn bowel habit,Rectal bleeding,anemia,abd bleeding,anemia,abd painpain

Ca, Ca, diverticuli,stricture,megacdiverticuli,stricture,megacolon.olon.

Difficult in elderly.Difficult in elderly.

incontinance.,incontinance.,

No biopsy.No biopsy.

Tests of structure: ImagingTests of structure: Imaging U/S,CT,MRI:U/S,CT,MRI:Increasingly used for abd diseases, noninvasive & offer detailed Increasingly used for abd diseases, noninvasive & offer detailed

images of abd contents.images of abd contents.

IndicationsIndications Major usesMajor uses LimitationsLimitationsUS:US: Masses,abscess,organs,ascites,bilMasses,abscess,organs,ascites,bil

iary dilation,gall stones,guided iary dilation,gall stones,guided needle aspiration & biopsy.needle aspiration & biopsy.

Low sensitive for small ls.Low sensitive for small ls.

Little functional info.Little functional info.

Operator dependent.Operator dependent.

Gass & obesity interfer with it.Gass & obesity interfer with it.

CT:CT: Pancreatic dis,liver tumor Pancreatic dis,liver tumor deposits, tumor staging, deposits, tumor staging, vascular lesions.vascular lesions.

Expensive,high radiation, Expensive,high radiation, may underestimate stage of may underestimate stage of cancers as esophagus.cancers as esophagus.

MRI:MRI: Tumor Tumor stage,MRCP,pelvic/perinestage,MRCP,pelvic/perineal, chrons fistula.al, chrons fistula.

Time consuming.Time consuming.

Clusterphobia,role not Clusterphobia,role not fully established,limited fully established,limited availability.availability.

Tests of structure: endoscopyTests of structure: endoscopy Endoscpy: UGI, LGI, Enteroscopy, ERCP,EUS , Double balloon endoscopy, capsule Endoscpy: UGI, LGI, Enteroscopy, ERCP,EUS , Double balloon endoscopy, capsule

video endoscopy.video endoscopy. Increasingly used for abd diseases, noninvasive & offer detailed images of abd contents.Increasingly used for abd diseases, noninvasive & offer detailed images of abd contents.

Tests of structure: endoscopyTests of structure: endoscopy

Endoscpy: UGI: Endoscpy: UGI: Indications:Indications: Dyspepsia sp > 45.Dyspepsia sp > 45. Abd pain.Abd pain. Atypical chest pain.Atypical chest pain. DysphagiaDysphagia Vomiting.Vomiting. Wt loss.Wt loss. Acute or chronic GIB.Acute or chronic GIB. Suspicious Ba meal.Suspicious Ba meal.

Tests of structure: endoscopyTests of structure: endoscopy

Endoscpy UGI: Endoscpy UGI: contraindications:contraindications: Severe shock.Severe shock. Recnet AMI, Unstable angina or arrhythmia.Recnet AMI, Unstable angina or arrhythmia. Severe resp dis.Severe resp dis. Atlanto axial sublaxation.Atlanto axial sublaxation. Suspected perforated viscus.Suspected perforated viscus. These may be relative in experienced hands.These may be relative in experienced hands. Endoscpy UGI: Complications:Endoscpy UGI: Complications: Cardiorespiratory depression due to sedation.Cardiorespiratory depression due to sedation. Aspiration pneumonia.Aspiration pneumonia. Perforation.Perforation. Bleeding.Bleeding. SBE( needs prophylaxis in those at risk).SBE( needs prophylaxis in those at risk).

Tests of structure: endoscopyTests of structure: endoscopy

Colonoscopy: Colonoscopy: indications:indications: Suspected IBD.Suspected IBD. Altered bowel habits.Altered bowel habits. Rectal bleeding or anemia.Rectal bleeding or anemia. Suspected abn Ba enema.Suspected abn Ba enema. CRC screening.CRC screening. Therapeutic procedure.Therapeutic procedure. C/Is:C/Is: Severe shock, Recent AMI, unstable angina & Severe shock, Recent AMI, unstable angina &

arrhythmias,Severe resp disease,Suspected perforation,severe arrhythmias,Severe resp disease,Suspected perforation,severe active UC.active UC.

Complications:Complications: As for upper GI endoscopy.As for upper GI endoscopy.

Examples of therapeutic techniques in endoscopy.

ERCP – DILATED COMMON BILE DUCTDUE TO MULTIPLEGALLSTONES

Tests of structure: BiopsyTests of structure: Biopsy Obtained through endoscpy or percutanously & sent for histopath exam.Obtained through endoscpy or percutanously & sent for histopath exam. Reasons for biopsy or cytological exams:Reasons for biopsy or cytological exams: Brash cytology of suspected malignant lesions.Brash cytology of suspected malignant lesions. Histological assessment of mucosal abns.Histological assessment of mucosal abns. Diagnosis of infections( candida, HP,Giardia).Diagnosis of infections( candida, HP,Giardia). Measure enzymes as disacharidases.Measure enzymes as disacharidases. Analysis of genetic mutations as oncogenes , tumor suppressor genes.Analysis of genetic mutations as oncogenes , tumor suppressor genes.

2.Tests of infection: Bacterial cultures2.Tests of infection: Bacterial cultures For identifying causes of diarrhea sp if acute or bloody.For identifying causes of diarrhea sp if acute or bloody. Causes of infective diarrhea:Causes of infective diarrhea: Viruses: Rota, adeno, entero, requires EM or viral cultures.Viruses: Rota, adeno, entero, requires EM or viral cultures. Bacteria: Campylo jej, EC,Salmonella,clostridium difficile( ned toxine isolation).Bacteria: Campylo jej, EC,Salmonella,clostridium difficile( ned toxine isolation). Protozoa: Giardia,ameba, cryptosporidium & moicrospora.Protozoa: Giardia,ameba, cryptosporidium & moicrospora.

Tests of infection: serologyTests of infection: serology Sp for HP, Salmonella, hydatid liver & ameba.Sp for HP, Salmonella, hydatid liver & ameba.

Tests of infection: radioactive breath testsTests of infection: radioactive breath tests For diagnosis for HP & small intestinal bacterial overgrowth.For diagnosis for HP & small intestinal bacterial overgrowth.

3.Tests of function: blood tests for 3.Tests of function: blood tests for malabsorptionmalabsorption

S.B12, folic acid, iron, Ca, alumin, phosphate,stool fat, endoscopic DU biopsy.S.B12, folic acid, iron, Ca, alumin, phosphate,stool fat, endoscopic DU biopsy. Tests for diagnosing fat, lactose,bile acids malabsorption.Tests for diagnosing fat, lactose,bile acids malabsorption. Tests of pancreatic exocrine functionTests of pancreatic exocrine function

Tests of function: GIT motilityTests of function: GIT motility Esophageal motlity:Esophageal motlity: Eso manometry with 24 hour Ph monitoring: for diagnosing refractory GERD, Achalasia & noncardiac chest pain.Eso manometry with 24 hour Ph monitoring: for diagnosing refractory GERD, Achalasia & noncardiac chest pain. Gastric motility:Gastric motility: Assessment of gastric emptying in patients with gastropariesis, is best evaluated by radioisotope studies by a test meal of solid & liquid labeled with different radioisotopes.Assessment of gastric emptying in patients with gastropariesis, is best evaluated by radioisotope studies by a test meal of solid & liquid labeled with different radioisotopes. Small intestine transit:Small intestine transit: Difficult & rarely needed.Difficult & rarely needed. Ba follow through can measure SI transit to reach TI( 90 min).Ba follow through can measure SI transit to reach TI( 90 min). Orocecal transit is measured by lactulose-hydrogen breathtest.Orocecal transit is measured by lactulose-hydrogen breathtest. Colonic & anorectal motility:Colonic & anorectal motility: Assessed by anorectal manometry, EP tests, defecating proctography.Assessed by anorectal manometry, EP tests, defecating proctography. Plain Abd XR taken on day 5 after ingestion of different-shaped inert plastic pellets on day 1-3 gives estimate of whole gut transit time.Plain Abd XR taken on day 5 after ingestion of different-shaped inert plastic pellets on day 1-3 gives estimate of whole gut transit time. Help to diagnose chronic idiopathic constipation from mechanical or obstructed defecation.Help to diagnose chronic idiopathic constipation from mechanical or obstructed defecation.

Tests of function: Radioisotope testsTests of function: Radioisotope tests Gastric emptying study: by Tc.Gastric emptying study: by Tc. Urea breath test: by radioactive Carbon: for HP diagnosis as HP have urease which split radioactive urea into amonia & CO2 measured in the breath.Urea breath test: by radioactive Carbon: for HP diagnosis as HP have urease which split radioactive urea into amonia & CO2 measured in the breath. Meckels sacn: TC.Meckels sacn: TC. Labeled RBC scan FOR DETECTING BLEEDING.Labeled RBC scan FOR DETECTING BLEEDING. Labled WBC scan: for detecting infection or inflammation.Labled WBC scan: for detecting infection or inflammation. Triolin test: C14 labeled trioliln: for fat malabsorption.Triolin test: C14 labeled trioliln: for fat malabsorption. Labelled albumin: to detect protein-losing enteropathy.Labelled albumin: to detect protein-losing enteropathy.