gastroenterology & its main clinical syndrome

7/24/2019 Gastroenterology & Its Main Clinical Syndrome

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Professor T.A. Dronova

LectureGASTROENTEROLOGY

MAIN CLINICAL SYNDROMES

KURSK STATEKURSK STATE

MEDICAL UNIVERSITYMEDICAL UNIVERSITY

Propaedeutics of InternalPropaedeutics of Internal

DiseasesDiseasesDDepartentepartent


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UPPER !ASTR"ENTISTINAL #LEEDIN!

Upper GI bee!"n# $ bee!"n# fro% es"on

of esop&a#us' sto%ac&' !uo!enu%

(above Tre"ts) "#a%ent*

Upper GI bee!"n# features+

,e%ate%es"s (vo%"t"n# of boo! or

cofee #roun! vo%"t"n#*

Meena Clinical features depend on rapidity & amount of

blood lost


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!ASTR"ENTISTINAL#LEEDIN!

,e%ate%es"s $ vo%"t"n# of boo! (br"#&t re! orcoffee #roun!*

Meena $ tarr- bac' st"c-' fou s%e"n# stoo

(ot&er stoo !arness $ "ron / b"s%ut& * Spec"a features+

a* appro0"%ate- 12 % of boo! "s re3u"re! topro!uce s"n#e bac stoo

b* t&e boo! oss 4 12 % pro!uces %eena for%ore t&an 5 !a-s

c* to pro!uce %eena t&e boo! %ust be "n t&e#ut for 6 &ours


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Etiolo$%

Co%%on causes 7

C&ron"c !uo!ena ucer

C&ron"c #astr"c ucer

Gastr"c eros"ons (eros"ve #astr"t"s*8ar"ces

Maor-$9e"s tear

Esop&a#"t"sDuo!ena eros"ons

Sto%ac& cancer

M"sceaneous

:;

:2

:2


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Su&se'uent cause e(aluation

Pept"c ucer !"sease> ep"#astr"c pa"n /&eartburn &"stor-

Gastr"c eros"ons> NSAIDs orcort"costero"!s us"n#

L"ver c"rr&os"s> s"#ns of c&ron"c "ver!"seases (?aun!"ce' pa%ar er-t&e%a'

euon-c&"a' sp"!er nev"'&epatospeno%e#a- / asc"tes*

Maor-$9e"s s-n!ro%e$ &"stor- offorcefu vo%"t"n# before &e%ate%es"s


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Clinical features

@ee!"n# fro% upper GIT %a- present "t&

&e%ate%es"s (rap"! bee!"n# presents as

&e%ate%es"s * or %eena (so bee!"n#

presents as %eena* ,e%ate%es"s $ vo%"t"n# of boo!

Cofee #roun! vo%"t"n# ("f boo! re%a"ns "n

sto%ac&' "t beco%es part"a- !"#este! /

appears bron "n t&e vo%"t*

Meena $ passa#e of bac stoos (after as "tte

as ;2$


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Se(ere &leedin$

S-%pto%s+

eaness' fa"ntness' nausea' seat"n#'

restessness / !"sor"entat"on

S"#ns+ postura &-potens"on 4


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UPPER !ASTR"ENTISTINAL #LEEDIN!Initial assessent ) &lood lost estiation C"n"ca ?u!#e%ent of !e#ree or rate of

bee!"n#

@P' puse / postura c&an#es (ort&ostat"c !rop

"n boo! pressure 4 "n!"cat"on of


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Initial assessent ) &lood lost estiation

In"t"a &e%o#ob"n eve / &e%atocr"t $ not

atere! unt" :$5= &ours (re!uce! &e%atocr"t

on a!%"ss"on to &osp"ta su##ests c&ron"c

bee!"n# pr"or to acute ep"so!e* R"se! boo! urea "t& nor%a seru% creat"n"ne

> oss of at east < "ter "n!"cat"on

Naso#astr"c tube passa#e $ assess"n#

pers"stent rate of bee!"n#


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In(esti$ations

En!oscop-

Seect"ve ab!o%"na an#"o#rap&-

Urea' creat"n"ne' eectro-tes

L"ver funct"on tests' protro%b"n

@oo! #roup"n# / cross %atc&"n#

@oo! test

Ra!"onuc"!e scan


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Mana$eent

Intravenous access' o0-#en' se!at"on

@oo! vou%e repace%ent

En!oscop-

P&ar%acoo#"ca %easures+

Proton pu%p "n&"b"tor

Octreot"!e

Sur#er-


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Eer$enc% ana$eent

,"stor- / e0a%"nat"on

Puse / @P %on"tor"n# &af$&our-

@oo! e0a%"nat"on for &e%o#ob"n' urea' cret"n"ne'

eectro-tes' boo! #roup"n# / cross %atc&"n# I8 "ne ("n br"s bee!"n# > centra "ne*

Nor%a sa"ne / boo! trasfus"on ("n!"cat"ons+ s&oc >

@P B


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Lo*er $astrointestinal &leedin$

Loer GI bee!"n# "s !ef"ne! as bee!"n#

ar"s"n# beo t&e "#a%ent of Tre"tF+

s%a "ntest"ne / coon

%a?or"t- of cases ar"se fro% coon /

part"cuar- t&e anorecta re#"on


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Etiolo$%Youn# pat"ents (beo ;2 -ears*+

Anorecta !"sease (&e%orr&o"!s' ana f"ssure*

Infect"ous co"t"s (S&"#ea' E. co"*

Infa%%ator- boe !"sease (ucerat"ve co"t"s*

O! pat"ents (above ;2 -ears*+

D"vert"cuos"s

An#"o!-spas"as

Neopas%s

Isc&e%"c co"t"s


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Si$ns Pa"ness bee!"n#$ "nterna &e%orr&o"!s'

!"vert"cuos"s' an#"o!-spas"a

@ee!"n# "t& pa"n$ "n ana f"ssure' "sc&e%"cco"t"s / "nfa%%ator- boe !"sease

,ae%atoc&eF"a$ br"#&t re! boo! fro%rectu%+

bee!"n# fro% ana / recta es"ons "n&e%orr&o"!s' f"ssures' f"stuas / carc"no%as

a%ount of boo! var- fro% fe !rops to%ass"ve bee!"n#


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+aeatoc,e-ia

It "s a passa#e of re! (or %aroon* boo! fro%

t&e rectu%' usua- s"#n"f"es bee!"n# fro% a

source !"sta to t&e "#a%ent of Tre"tF (beteen

!uo!enu% / s%a "ntest"ne* "t can aso occur fro% %ass"ve upper

#astro"ntest"na bee!"n# (fro% esop&a#us'

sto%ac& / !uo!enu%*

Appearance of blood in stool depends not

only on bleeding site but also on hemorrhage

rate & rapidity of transit


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Patient e(aluation D"vert"cuos"s+ pa"ness %aroon or br"#&t re!

&e%atoc&eF"a "n pat"ent 4 ;2 -ears of a#e' bee!"n#stops spontaneous-

An#"o!-spas"a+ pa"ness bee!"n# "n pat"ent 4 52 -ears

Neopas%+ ben"#n / %a"#nant > usua- "t& c&ron"coccut bee!"n# Infa%%ator- boe !"sease (ucerat"ve co"t"s*+ !"arr&ea

"t& occut bee!"n# or recurrent &e%atoc&eF"aassoc"ate! "t& ab!o%"na pa"n' tenes%us / ur#enc-

Anorecta !"sease &e%orr&o"!s > pa"ness bee!"n#%"0e! "t& stoo or !r"pp"n# "nto to"et bo' pa"nfus%a bee!"n# "n ana f"ssure

Isc&e%"c co"t"s > e!er- pat"ent "t& aterosceros"s >boo!- !"arr&ea "t& %"! ab!o%"na cra%ps


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C"L"NIC DISEASE

Rectal &leedin$

D"a#nost"c stoo appearance+

Blood coating exterior of formed stool - lesion in

anal canal or rectum

Blood admixed with feces - bleeding source higherin colon

Brisk hemorrhage from colon or distal small

intestine - passage of fresh blood (hematochezia): fresh blood & clots - lesion in left colon

dark, maroon-colored blood - bleeding from right

colon


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Dia$nosis Se3uence of !"a#nost"c toos+ ev"!ence of anorecta !"seases' I"nfa%%ator- boe

!"sease or "nfect"ons co"t"s

:. E0cu!e upper GI bee!"n# > naso#astr"c tube

=. Tec&net"u%$ scan > to !etect act"ve bee!"n# course

. An#o"#rap&- (c&o"ce %et&o!* > rap"! oca"Fat"on

;. Coonoscop- ("f bee!"n# stops* > "!ent"f"cat"on of

an#"o!-spaF"a' t"ssue b"ops-


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P,%sical e.aination

in colonic diseases D"#"ta recta e0a%"nat"on (per"ana'

sp&"nter"c / a%puar- es"ons' prostat"c /

uter"ne abnor%a"t"es' recta %asses /

%etastat"c tu%or "n per"recta t"ssues $@u%er)s s&ef

Heca %ater"a on #ove $ "%%e!"ate test "t&

#ua"ac$"%pre#nate! car!s for occut boo!


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@e! rest' se!at"on / transfus"on

Stop asp"r"n / ot&er NSAIDs

T&erapeut"c coonoscop-+ en!oscop"c

eectrocoa#uat"on of an#"o!-spas"a

Intra$arter"a vasopress"on or e%bo"Fat"on

(27 effect"ve "n !"vert"cuu% or

an#"o!-spas"a* Sur#er-


Mana$eent


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"ccult $astrointestinal &leedin$

Loss of s%a a%ounts of boo! "nto GIT >

present "n stoo' but no &e%atoc&eF"a or

%eena

Met&o!s for !etect"on+ Pos"t"ve feca occut boo! test

Iron !ef"c"enc- ane%"a "n a!ut


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Etiolo$%

A causes of upper / oer #astro"ntest"nabee!"n# > co%%on causes+

Tu%ors+ ben"#n or %a"#nant tu%ors of an-

s"te "n GIT espec"a- > coon canser Pept"c ucer / esop&a#"t"s

NSAIDs

An#"o!-spas"a

Infect"ons (&oo or% > %ost co%%on cause*

Ma?or causes+ ceca carc"no%a /an#"o!-spas"a (arter"ovenous %afor%at"on&"c& can be v"s"be on coonoscop-*


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In(esti$ations

9eber)s #ua"ac test>

!etect"on of &e%o#ob"n pero0"!ase+

=$; # of feces %"0e! "t& stron# acet"c ac"!

(se%""3u"! paste* > %"0ture stan!s for =2%"n.


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In(esti$ations

Gre#ersen)s benF"!"ne test>

Propert- of &e%o#ob"n to cata-se o0"!at"on$

re!uct"on react"ons+

,-!ro#en p"ro0"!e


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#lood in stool

@oo! %"0e! "t& stoo+ eft s"!e! coon"c

tu%or' "nfa%%ator- boe !"sease' !"vert"cuar

!"sease' "nfect"ve co"t"s / an#"o!-spas"a

Hres& boo! "n s%a a%ounts+ &e%orr&o"!s'Cro&n)s !"sease of t&e anus' carc"no%a of t&e

rectu%

Severe bee!"n# (rare* + !"vert"cuar !"sease /

"sc&e%"c co"t"s


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Difference &et*een upper /

lo*er $astrointestinal &leedin$

Heatures Upper#astro"ntest"nabee!"n#

Loer#astro"ntest"nabee!"n#

S"te Above Tre"ts)"#a%ent (esop&a#us'sto%ac&' !uo!enu%*

@eo Tre"ts)"#a%ent (s%a"ntest"ne / coon*

Presentat"on ,e%ate%es"s

Cofee #roun!vo%"t"n#

Meena

,e%atoc&eF"a


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Difference &et*een upper /

lo*er $astrointestinal &leedin$

Heatures Upper#astro"ntest"nabee!"n#

Loer#astro"ntest"nabee!"n#

Naso#astr"casp"rat"on

@oo! Cear fu"!

@oesoun!s

,-peract"ve Nor%a


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MALA#S"RPTI"N

Maabsorpt"on $ "na!e3uate transport of one

or %ore of const"tuents of nor%a !"et fro%

"ntest"na u%en across "ntest"na ep"t&e"u%

"nto porta c"rcuat"on CLINICAL HEATURES+

D"arr&ea

Ab!o%"na pa"n D"stens"on

9e"#&t oss

Nutr"t"ona !ef"c"enc"es


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Nutrient a&sorption

SitesDuo!enu%+iron, calcium, magnesium,folic acid, water soluble itamins, amino

acids, monosaccharides

Je?unu%+fatt! acids, amino acids,

monosaccharides, water soluble itamins

Ieu%+ monosaccharides, fatt! acids,

amino acids, fat soluble itamins (", #, $,

%), itamin B' & conugated bile salts


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Nutrient a&sorptionP,%siolo$% 0 1 p,ases

Lu%"na p&ase+ &-!ro-s"s /

soub""Fat"on of nutr"ents

Mucosa p&ase+ furt&er brea!on ofnutr"ents / transfer "nto ce

Transport p&ase+ re%ova of nutr"ents

"nto vascuar or -%p&at"c c"rcuat"on


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23 Intraluinal ala&sorptionDisoders

Pancreat"c "nsuff"c"enc-+

C&ron"c pancreat"t"s

C-st"c f"bros"s (autoso%a !"sease*

Carc"no%a of pancreas

Def"c"enc- of b"e ac"!s+

Entero&epat"c c"rcuat"on "nterrupt"on (resect"on orter%"na "eu% !"sease*

S%a "ntest"ne coon"Fat"on "t& bacter"a &"c&

!econ?u#ate b"e ac"!s (sta#nant oop s-n!ro%e* Uncoor!"nate! #astr"c e%pt-"n#+

Gastroenterosto%-

Part"a #astrecto%-


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43 Mucosal p,ase ala&sorptionDisoders Genera"Fe! %ucosa abnor%a"t"es(&"stoo#"ca-

abnor%a %ucosa*+

Coe"ac !"sease (#uten$sens"t"ve enteropat&-*

Tubercuos"s

Trop"ca sprue

L-%p&o%a

Ra!"at"on enter"t"s

9&"ppe)s !"sease (%acrop&a#es "nf"trat"on* Maabsorpt"on of spec"f"c substances(&"stoo#"ca-

nor%a %ucosa*+

Lactase !ef"c"enc-


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13 Transport p,ase ala&sorption

Disoders

8ascuar+ vascu"t"s' at&erosceros"s

L-%p&at"c+ -%p&an#"ectas"a'"nf"trat"ons


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Mala&sorption S%ndroe

S%ptos

GIT s-ste%

Gen"tour"nar- s-ste%

,e%atopoet"c s-ste%Muscuoseeta s-ste%

Nervous s-ste%

S"n


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MALA#S"RPTI"N

Nutr"t"ona!ef"c"enc"es

Heatures

Hats Steatorr&ea' frot&-stoos' ater- !"arr&ea'e"#&t oss

Carbo&-!rates Hatuent !-speps"a(borbor-#%us*'

ab!o%"na !"stens"on'fatus' ater- !"arr&ea


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MALA#S"RPTI"N


Heatures

Prote"n 9e"#&t oss' %usce ast"n#'

&-poabu%"nur"a' oe!e%a'eucon-c&"a

Ho"c ac"! Macroc-t"c'

%e#aobast"c ane%"a'#oss"t"s' ora %ucosaucerat"on "n fo"c ac"!

!ef"c"enc-


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MALA#S"RPTI"N


Heatures

8"ta%"n @


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MALA#S"RPTI"N


Heatures

8"ta%"n C @ee!"n# ten!enc-

8"ta%"n A Ho"cuar&-pereratos"s'0eropt&a%"a' n"#&tb"n!ness


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MALA#S"RPTI"N


Heatures

8"ta%"n D /

Cac"u%

Osteo%aac"a(r"cets*' pro0"%a%-opat&-'paraestes"a' tetan-

8"ta%"n K Purpura'&e%orr&a#es(bru"s"n# / bee!"n#*


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MALA#S"RPTI"N


Heatures

Iron ,-poc&ro%"c ane%"a'c&e"os"s' spoon$s&ape!na"s (o"on-c&"a*'

apt&ous ucers

So!"u% Muscuar eaness'cra%ps


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MALA#S"RPTI"N


Heatures

Potass"u% Hacc"!"t-'arr&-t&%"as

Ma#nes"u% Muscuar eaness'paraestes"a' tetan-

9ater Nocturna !"ures"s


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MALA#S"RPTI"N


Heatures

"nc Poor taste' !er%at"t"s'poor oun! &ea"n#

@"e sats 9ater- !"arr&ea


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!ASTRIC "UTLET "#STRUCTI"N

5PYL"RIC STEN"SIS6

Et"oo#-+

Pept"c ucer "n t&e re#"on of p-orus

(%a- ea! to #astr"c outet obstruct"on*

!ue to e!e%a' spas%' f"brous str"cture

Duo!ena ucer

Carc"no%a of antru%


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5PYL"RIC STEN"SIS6

irst - narrowing is compensated b! h!pertroph!

of the gastric muscles

*ater - stomach becomes distended, food sta!s

inside for longer period & fermentation &putrefaction occurs in the stomach

"bsorption of water impaired

+pset of water-salt balance causing generaldeh!dration of the bod! & decrease of chloride

content in the blood & urine


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5PYL"RIC STEN"SIS6

Lon# &"stor- of pept"c ucer "t& pro%"nent

nausea / vo%"t"n#

9"t&out s-%pto%s of pept"c ucer > p-or"c

carc"no%a

8o%"t"n# $ str""n# re"ef

8o%"tus+ aa"ne react"on (presence ofa%%on"a co%poun!s* of foo! part"ce &ave

been eaten : &ours or 4 prev"ous-


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!ASTRIC "UTLET "#STRUCTI"N5PYL"RIC STEN"SIS6Clinical features per%anent pa"n (&"c& "ntens"f"es at n"#&t*

eructat"on "t& rotten e## "n!

vo%"t"n# "t& foo! t&at as "n#este! severa

!a-s a#o const"pat"on "s aternate! "t& !"arr&ea

t&rou#& "rr"tat"on of t&e s%a "ntest"ne b-fer%ente! foo! !"sc&ar#e! "nto "t fro% t&e

p-orus t&at "s opene! b- "ntens"f"e!per"stas"s

aaos"s !eveops "f ar#e a%ount of ,C "sost "n vo%"t"n#


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!ASTRIC "UTLET "#STRUCTI"N5PYL"RIC STEN"SIS6Clinical features

9ast"n# (cac&e0"a* !ue to un!ernour"s&%ent

De&-!rat"on

E0a%"nat"on of t&e ep"#astr"u%+ per"stas"s /

ant"per"stat"c contract"ons of t&e sto%ac& $v"s"be #astr"c per"stas"s(per"stas"s ave

pro#ress"n# fro% eft &-poc&on!r"u% /

ep"#astr"c re#"on toar!s r"#&t u%bar re#"on*

Late spas&"n# soun! (,"ppocrates) s"#n* 4 5$6&ours after ast %ea or !r"n ("n &eat&- person

spas&"n# soun! (succus"on* B < &our after

%eas because #astr"c e%pt-"n# "s rap"!*


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!ASTRIC "UTLET "#STRUCTI"N5PYL"RIC STEN"SIS6

In(esti$ationAsp"rat"on of sto%ac& contents+ vou%e

4


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!ASTRIC "UTLET "#STRUCTI"N5PYL"RIC STEN"SIS6

In(esti$ationEn!oscop-+

Les"on at p-orus

Increase "n fast"n# res"!ue of sto%ac&foo!

Seru% eectro-tes !epet"on


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5PYL"RIC STEN"SIS6

Mana#e%ent

Asp"rat"on+

Not&"n# per os

:$ &our- asp"rat"on for =$ !a-s ("f asp"rat"onvou%e !ecrease! > fu"! b- %out&*

I8 fu"! > re&-!rat"on

8"ta%"ns Sur#er-


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INTESTINAL "#STRUCTI"N

: t-pes of "ntest"na obstruct"on

S"%pe or !-na%"c+ per"stas"s or"n#

a#a"nst obstruct"on a#ent "n t&e "ntest"na

u%en' "n t&e a or outs"!e t&e a (feca"%pact"on' str"cture or a!&es"on*

Stran#uat"on or a!-na%"c+ per"stas"s ceases

/ no propus"ve ave occurs $ "t& "ntest"na

boo! supp- &en t&e boe "s trappe! or

t"ste! (para-t"c "eus or %esenter"c vascuar

occus"on*


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Etiolo$%

Lu%"naobstruct"on

Heca "%pact"onGastone "eus9or%s (ascar"!"as"s*

Intr"ns"ces"ons ofboe a

Tu%ors of ar#e "ntest"neStr"ctures (tubercuos"s' Cro&n)s!"sease*Intussuscept"on

E0str"ns"cco%press"on

A!&es"on,ern"as8ovuus

Para-t"c "eus Per"ton"t"s

Postoperat"ve8ascuar


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Clinical features

Pa"n+

Co"c- pa"n "n %ec&an"ca obstruct"on

Du constant pa"n "n para-t"c "eus8o%"t"n#+

Cop"ous > "n &"#& s%a boe

obstruct"onLate or absent > "n oer s%a boe or

coon obstruct"on


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Clinical features

Ab!o%"na !"stent"on D"stent"on conf"ne! to so%e oops of boe $

r"!#es across t&e ab!o%en for%"n# La!!erPattern) $ v"s"be "ntest"na per"stas"s$ !"sta

s%a boe obstruct"on+ step a!!er for%ofper"stas"s aves (%ot"e s%a "ntest"ne* "nu%b""ca re#"on

Later !"ffuse !"stent"on > "n!"cat"on of c&ron"c

ar#e boe obstruct"on or para-t"c "eu% Co%pete obstruct"on $ feaces / fatus not

passe! H"rst $ "ncrease! boe soun!s' ater $ absent

per"stat"c soun!s


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In(esti$ation

H"n#er e0a%"nat"on of rectu%+baoone! / e%pt- rectu% (Obu&ov)s

&osp"ta or Greov)s s"#n*

Pa"n $ra- ab!o%en ("n erect / sup"ne

pos"t"on* $ #aseous !"stent"on /"ntest"na fu"! eves (Ko"ber)s cups $

&or"Fonta fu"! eve / #as bubbe*


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Mana#e%ent

Not&"n# per os

Deco%press"on (#astro"ntest"na !ra"na#ev"a naso#astr"c tube*

I8 fu"! / eectro-tes

Ant"b"ot"cs

Sur#er-


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ACUTE A#D"MEN

ACUTE A@DOMEN> a ter% use! to

!ef"ne a #roup of ab!o%"na

con!"t"ons "n &"c& pro%pt sur#"ca

treat%ent %ust be cons"!ere!


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ACUTE A#D"MEN

CAUSES@oe

Acute appen!"c"t"s

Perforate! pept"c ucer or ab!o%"na v"scus

D"vert"cuar !"sease

Intest"na obstruct"on / stran#uat"on

Mece)s !"vert"cuu%

Ter%"na "e"t"s (Yers"n"a "nfect"on*

ACUTE A#D"MEN


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ACUTE A#D"MEN

CAUSES8ascuar

Acute vascuar "nsuff"c"enc-

Rupture! aort"c aneur-s%

G-necoo#"ca

Rupture! ectop"c pre#nanc-

Rupture! ovar"an c-st Acute sap"n#"t"s

ACUTE A#D"MEN


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ACUTE A#D"MEN

CAUSESOt&ers

C&oec-st"t"s

Acute pancreat"t"s

Acute %esenter"c a!en"t"s

Me!"ca causes of ab!o%"na pa"n

MIMIC ACUTE A#D"MEN


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MIMIC ACUTE A#D"MEN

MEDICAL C"NDITI"NSCo%%on

M-ocar!"a "nfarct"on

Pneu%on"a

Peur"s- Acute p-eonep&r"t"s

Irr"tabe boe s-n!ro%e

Tons""t"s' ot"t"s %e!"a "n c&"!ren

Unco%%on

D"abet"c etoac"!os"s

Acute porp&-r"a

A#D"MINAL PAIN


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A#D"MINAL PAIN

MEC+ANISMS


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A#D"MINAL PAIN

MEC+ANISMS :.Referre! pa"n a* Hro% t&e c&est (%-ocar!"a "nfarct"on' peur"s-*

b* Hro% t&e vertebra cou%n (nerve root

co%press"on' %uscuoseeta !"sor!ers* c* Hro% t&e #ona!s (tors"on of t&e testes*

=.M"sceaneous

a* Metabo"c !"sor!ers (urae%"a' !"abetes'porp&-r"a' &-percacae%"a' A!!"sonQs !"sease*

b* Ps-c&o#en"c !"sturbances ("rr"tabe boe

s-n!ro%e*

ACUTE A#D"MEN


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ACUTE A#D"MEN

Clinical picture Paro0-s% of severe ab!o%"na pa"n Per"tonea "rr"tat"on s"#ns (resp"rator- ab!o%en

e0curs"ons absent' S&c&et"n$@u%ber# s"#n *

S"#ns of !"sor!ere! per"stas"s / tone of GIT (nausea'

vo%"t"n#' pronounce! %eteor"s%' const"pat"on'passa#e of fatus' v"s"be per"stas"s > 9a&)s s"#n*

C"rcuator- coapse+ paor' s-ncope' co! seat'

rap"! / ea puse' o @P' p"nc&e! face (fac"es

,"ppocrat"ca*

Genera rap"!- pro#ress"n# s"#ns of "nfa%%at"on+

fever' neutrop&""c eucoc-tos"s' acceerate! ESR


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Locali-ation of a&doinal pain

Or#an E0terna oca"Fat"onon ab!o%"na a

Sto%ac& /!uo!enu%

Ep"#astr"u%' %"!"neor s"#&t- to t&e r"#&t

Transverse / s"#%o"!coon

Per"u%b""ca or r"#&t""ac fossa


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R"#&t coon R"#&t oer 3ua!rant

Left coo% Left oer 3ua!rant


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Rectos"#%o"! Suprapub"c

@a!!er Suprapub"c


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Rectu% Loer bac' %"!"ne

Gaba!!er M"! ep"#astr"c'

ra!"at"n# to r"#&tupper 3ua!rant / tor"#&t scapuar area


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Co%%on b"e !uct M"! ep"#astr"c'

ra!"at"n# to s&ou!eror retrosterna- tonec

Pancreas M"! ep"#astr"c'sprea!"n# atera- tobac "f poster"orper"toneu% "s"nvove!

ACUTE A#D"MEN


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ACUTE A#D"MEN

Clinical picture

,"stor-


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ACUTE A#D"MEN

Clinical picture

Ton#ue furre! "n %ost acute ab!o%"na

!"sease

Te%perature fever %ore co%%on "n

acute "nfa%%ator- con!"t"ons

ACUTE A#D"MEN


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ACUTE A#D"MEN

Clinical picture

E0a%"nat"on

a* S"#ns of per"ton"t"s

S"te of ten!erness

Guar!"n# > oca"Fe! or #enera"Fe! Reboun! ten!erness

b* S"#ns of obstruct"on

D"stens"on of ab!o%en !ue to #as Increase! #ut soun!s (borbor-#%"*

Absent #ut soun!s su##est per"ton"t"s

ACUTE A#D"MEN


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ACUTE A#D"MEN

In(esti$ations

Pev"c / recta e0a%"nat"on

Pev"c e0a%"nat"on for #-necoo#"ca !"sor!ers

(rupture! ectop"c pre#nanc-*

Recta e0a%"nat"on to !etect oca"Fe! ten!erness !* Ot&er observat"ons+

Ur"n"e ana-s"s for+

a* Gucose / Ketones (for !"abet"c etoac"!os"s*

b* 9@C > to e0cu!e acute p-eonep&r"t"s

c* P&orp&-r"ns $ to !etect porp&-r"a (rare

con!"t"on*

ACUTE A#D"MEN


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ACUTE A#D"MEN

In(esti$ations / treatent

,osp"ta"Fat"on

,our- ta"n# bo!- te%perature

Tota boo! counts

ECG

Ra!"o#rap&"c ab!o%en e0a%"nat"on (R$scop- /

R$#rap&-*

Sur#er-

ACUTE APPENDICITIS


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ACUTE APPENDICITIS

SYMPT"MS

ain begins as ague, central abdominal pain(around umblicus or epigastrium) & shifts to the

right iliac fossa within a few hours

'. "norexia (preceding the pain)

/. 0ausea & omiting (omiting is not so

fre1uent)

2. 3onstipation or diarrhoea: mostl! patients with

appendicitis deelop constipation for a few da!s

before the attack of the pain - a few patients

hae diarrhoea

ACUTE APPENDICITIS


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ACUTE APPENDICITIS

SI!NS


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ACUTE APPENDICITIS

Confirator% si$ns


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ACUTE APPENDICITIS

INVESTI!ATI"NS / TREATMENT

IN8ESTIGATIONS

@oo! CP+$ S&os eucoc-tos"s (on-

reac&"n# upper "%"ts $ not so %are!* TREATMENT

Appen!ecto%-


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!ASTRIC 7UICE ANALYSIS

Naso#astr"c tube $ "nto sto%ac&

Gastr"c contents asp"rate!+


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Deb"t$&our of ,C $ a%ount of free ,CL secrete!!ur"n# < &our

Hor%ua+ D ( ,C * A @ 2.2=1;

D ( ,C * $ !eb"t$&our of ,C A $ a%ount of #astr"c ?u"ce secrete! "n < &our

@ $ ac"!"t- of #astr"c ?u"ce "n t"trat"n# un"ts

2.2=1; $ %oecuar e"#&t of ,C

Nor%a @AO eve ran#es fro% ;2$


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!ASTRIC 7UICE E8AMINATI"N

Hast"n# sto%ac& ;2 %

,our- basa secret"on =2 $ b- #astr"c ?u"ce vou%e

(after parentera st"%uants or :; %"n. after test%ea* 5; %

,our- secret"on after st"%uat"on+

12 % ("nter%"ttent asp"rat"on*


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Pat&oo#"ca c&an#es+ Leve above nor%a @AO (;2$

&-perc&or&-!r"a Leve beo nor%a @AO (;2$


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INCREASED !ASTRIC SECRETI"N

5+YPERSECRETI"N6

,-persecret"on $ abnor%a "ncrease "n #astr"c?u"ce a%ount

Gastr"c &-perac"!"t- or &-perc&or&-!r"a $e0cess"ve #astr"c ac"!"t-

,-persecret"on+ #astr"c ?u"ce 4


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DIMINIS+ED !ASTRIC SECRETI"N

5+YP"SECRETI"N6

,-poc&or&-!r"a $ secretor- funct"on"%pa"r%ent "t& re!uce! free ,C

secret"on "n sto%ac&

Anac"!"t- or ac&or&-!r"a $ secretor-funct"on "%pa"r%ent "t& tota- absent

,CL

Gastr"c ac&-"a $ s"%utaneous absent ofpeps"n / ,C fro% #astr"c ?u"ce



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5+YP"SECRETI"N6

,C / peps"n %a- !"sappear as resut of

funct"ona !"sturbances (causes !"fferent"ate!

b- %eans of &"sta%"ne test*

Or#an"c sto%ac& es"ons $ ,C not secrete!even after &"sta%"ne "n?ect"ons

Hunct"ona !"sor!er $ free ,C "n #astr"c

content



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5+YP"SECRETI"N6

Absence of free ,C $ often "n !"seasesacco%pan"e! b- to0"cos"s / !eran#e%ent of

CNS funct"on caus"n# "n&"b"t"on of sto%ac&

secret"on

Or#an"c ac&-"a > "n atrop&"c processes "n

#astr"c #an!s !ue to "nfa%%ator- c&an#es'

%anutr"t"on' prote"n / v"ta%"n !ef"c"enc- "n

foo! Ma"n s"#ns+ #astr"c / "ntest"ne !-speps"a

! t i + t


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!astric p+0etr%

Nor%a p, "n esop&a#us $ neutra or s"#&t-aa"ne (5'2$5':*

Nor%a p, "n sto%ac&+

car!"a ver"tabe ac&or&-!r"a

! t i + t


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!astric p+0etr%

After "n#est"on of 2.; %# of Na,CO='sto%ac& p, "ncreases for about :2 %"n. /

t&en returns to "n"t"a eve

Decrease! esop&a#us p, $ #astro$esop&a#ea refu0

Neutra #astr"c p, $ ac&-"a

Increase of #astr"c p, after a!%"n"strat"onof Na,CO= 4=2 %"n. $ !uo!eno#astr"c

refu0 suspecte!

INADE9UATE DI!ESTI"N


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INADE9UATE DI!ESTI"N

SYNDR"ME

Upset cav"ta !"#est"on+ sto%ac& /"ntest"na !-speps"a

Upset par"eta !"#est"on

M"0e! for%

DYSPEPSIA $ ter% use! as coect"ve

!escr"pt"on for var"et- of

a"%entar- s-%pto%s

D i


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D%spepsia

SYMPTOMS INCLUDED IN TERM DYSPEPSIA

Upper ab!o%"na pa"n (%a- or not be reate! to

foo!*

Gastro$oesop&a#ea re#ur#"tat"on / &eartburn Anore0"a' nausea / vo%"t"n#

Ear- repet"on or sat"et- after %eas

A sense of ab!o%"na !"stens"on or boat"n#)(sense of ab!o%"na !"stens"on*

Hatuence (burp"n#' bec&"n#* / aerop&a#-

D%spepsia


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D%spepsia

Etiolo$%

Non$co%pensate! secretor- sto%ac&"nsuff"c"enc-

E0ocr"ne pancreas !-sfunct"on

Upset b"e secret"on D"sor!ere! c&-%e passa#e t&rou#& GIT+

stas"s' stenos"s' "ntest"na co%press"on'

"ntense per"stas"s > acceerate! passa#e

Intest"na "nfect"on / !-sbacter"os"s

A"%entar- !"sor!ers (overeat"n#' !"et r"c& "n

prote"n' fat' carbo&-!rate*

D%spepsia


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D%spepsia

Most coon causes

Sto%ac& !"sor!ers (atrop&"c #astr"t"s "t&ac&-"a or ac&or&-!r"a' sto%ac& cancer*

Intest"na !"sor!ers (enter"t"s*

D"sor!ers of re#uat"on of !"#est"ve process(so$cae! funct"ona !-speps"a $ "n!epress"on*

L"ver !"sor!ers (&epat"t"s' "ver c"rr&os"s*

D"sor!ers of pancreas (c&ron"c pancreat"t"s* En!o#enous (ure%"a' !"abet"c etoac"!os"s*

or e0o#enous (aco&o* "nto0"cat"ons

D%spepsia


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D%spepsia

Pat,o$enesis

Inco%pete brea!on of foo! part"ces

Act"ve propa#at"on of "ntest"na bacter"a fora

D-sbacter"os"s

Hunct"ona !-speps"a $ ps-c&oo#"ca factors

!astric D%spepsia


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!astric D%spepsia

Etiolo$% D-speps"a $ co%%on- assoc"ate! "t&

or#an"c !"seases of upper GIT+

Pept"c oesop&a#"t"s

Ac&or&-!r"a / ac&-"a

Pept"c ucer

Gastr"c carc"no%a

P-or"c stenos"s

Gastr"t"s

!astric D%spepsia


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!astric D%spepsia

Clinical picture Hee"n# of !"sco%fort Ep"#astr"u% pressure or !"stens"on after %eas Hre3uent eructat"on Re#ur#"tat"on (often "t& ac"! or fet"! o!or* Unpeasant taste "n %out& Nausea Poor appet"te

Ac&-ous !"arr&oea Meteor"s%

Gastr"c ?u"ce e0a%"nat"on >

ac&or&-!r"a or ac&-"a (peps"n / ,CL absence*

:unctional D%spepsia


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:unctional D%spepsia5Non ulcer d%spepsia6

Co%pa"nts of pers"stent !-speps"a "t&

e0cu!e! or#an"c causes $ non ucer

funct"ona !-speps"a

S-%pto%s of !"sturbance "n %otorfunct"on

of GIT !ue to ps-c&oo#"ca factors

Pat"ents $ usua- -oun# (beo 2 -ears *'

o%en %en :+ "n!"cat"on of presence ofacute "nfa%%ator- e0u!ates (ucerat"ve co"t"s' a%eb"cco"t"s / bac"ar- !-senter-*

H"0e! / sta"ne! s"!es of stoo for a%oebas / ot&erparas"tes

Stoo cuture $ for !"a#nos"s of bac"ar- !-senter- Su!an III sta"n of stoo $ screen"n# test for steatorr&ea

DIARR+"EA


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DIARR+"EA

Stoo e"#&t "ncrease 4 =22 # per !a-acco%pan"e! b- "ncrease! stoofre3uenc-

T-pes+Os%ot"c !"arr&eaSecretor- !"arr&ea Infa%%ator- !"arr&eaAb!o%"na %ot""t- !"arr&eaAnt"b"ot"c$assoc"ate! !"arr&ea

"sotic diarr,ea


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"sotic diarr,ea

Lar#e 3uant"t"es of non absorbe! &-perton"csubstances "n #ut u%en present >

fu"! enters boe !ue to os%ot"c pressure+

Pur#at"ve "ntae

Genera"Fe! %aabsorpt"on

Spec"f"c %aabsorpt"on (!"sacc&ar"!ase!ef"c"enc-*

Os%ot"c !"arr&ea stops &en pat"ent stops

eat"n# of %aabsorpt"ve substances

Secretor% diarr,ea


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Secretor% diarr,ea

Act"ve "ntest"na secret"on of fu"! /eectro-tes "t& !ecrease! absorpt"on+

Enteroto0"n (c&oera' E.co"*

@"e sats "n coon foo"n# "earesect"on

Hatt- ac"!s "n coon foo"n# "ea

resect"onHoo! !oes not affect !"arr&ea $ cont"nues!ur"n# fast"n#

Inflaator% diarr,ea


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Inflaator% diarr,ea

Da%a#e to "ntest"na %ucosa ces $oss of fu"! / boo!+

D-senter- (S&"#ea*

Ucerat"ve co"t"s

A&doinal otilit% diarr,ea


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A&doinal otilit% diarr,ea

Not true !"arr&ea $ vou%e /

e"#&t of stoo "s not "ncrease! "t&

"ncrease! fre3uenc- of

!efecat"on+

Irr"tabe boe s-n!ro%e

D"abet"c neuropat&-T&-roto0"cos"s

Anti&iotic0associated diarr,ea0


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Pseudoe&ranous colitis

After ta"n# ant"b"ot"cs (part"cuar-

a%p"c""n' "nco%-c"n / cep&aospor"n $

pro!uce pseu!o%e%branous co"t"s*S"#%o"!oscop- $ %ut"pe -eo pa3ues

/ "nfa%%at"on

Difference &et*een sall &o*el


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/ lar$e &o*el diarr,ea

Heatures S%a boe!"arr&ea

Lar#e boe!"arr&ea

Stoovou%e

Lar#e S%a

Stoo coour L"#&t Dar



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Lar#e boe!"arr&ea

Stoo s%e 8er- fou Hou

Stoo nature Soup- /#reas- Muc"nous /?e- "e



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Lar#e boe!"arr&ea

Stoo t-pe 9ater- Muco"!

@oo! "nstoo

Rare ("fpresent >

atere!*

Co%%on (usua-> fres& boo!' "f

fro% caecu% >%aroon cooure!



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Lar#e boe!"arr&ea

9@Cs "nstoo

Rare Co%%on

Ab!o%"napa"nocat"on

Per"u%b""care#"on' %"!ab!o%en(cra%p- /"nter%"ttent*

Loer ab!o%en(#r"pp"n# /cont"nuos*



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Lar#e boe!"arr&ea

Tenes%us Absent Present

Un!"#este!

%ater"a

Ma- be

seen

Inv"s"be



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Lar#e boe!"arr&ea

Steatorr&ea Ma- beseen

Not seen

Hre3uenc- Less More

A&noral stool 0 o&;ecti(e e(idencef l i di


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of colonic disease

Stoo e0a%"nat"on b- p&-s"c"an $ as soon as poss"be after!efecat"on for presence of v"s"be boo! on surface or "t&"nt&e spec"%en' test for occut boo!

M"croscop"c e0a%"nat"on of fres& stoo $ !"a#nos"s ofparas"t"c !"seases (a%eb"c co"t"s $ %ot"e trop&oFo"ts "n

fres&' ar% stoo suspens"on* Stoo suspens"on sta"ne! "t& a !rop of %et&-ene bue for

po-%orp&onucear euoc-tes > "n!"cat"on of presence ofacute "nfa%%ator- e0u!ates (ucerat"ve co"t"s' a%eb"cco"t"s / bac"ar- !-senter-*

H"0e! / sta"ne! s"!es of stoo for a%oebas / ot&erparas"tes

Stoo cuture $ for !"a#nos"s of bac"ar- !-senter-

Su!an III sta"n of stoo $ screen"n# test for steatorr&ea


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Management


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g

7estoration of blood olume

- restoration of blood olume can be best

achieed b! transfusion of whole blood

- before blood arrangement, restored bloodolume with 8.9 normal saline and plasma

expender ( haemacel )

- the rate of blood transfusion must bemonitored carefull! to aoid oer transfusion

and conse1uent heart failure

Occult GI Bleeding


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Occult GI Bleeding

5s the lost of small amount of blood into tractwhich is present in stool but cannot be seen

( no hematochezia or melena )

it is t!picall! detected in of the ' settings :a) positie feacal occult blood test

b) the presence of iron deficienc! anemia in an

adult

Etiology


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"ll causes of upper and lower ;5 bleeding ma!

also cause occult bleeding, following are thecommon cases:

. 6umors : benign or malignant

- tumor of an! site of ;56, especiall! colon cancer

'. eptic ulcer and esophagitis

/. 0


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. 7ectal examination, anoscop! andsigmoidoscop! are performed to look for

eidence of anorectal disease, inflammator!

bowel disease or infectious colitis

- if source is identified, no further inestigations

are needed immediatel! unless bleeding persist

or is recurrent

'. $xclude an upper tract source : passnasogastric tube in patients with significant

bleeding to look for e idence of pper ;5 so rce

gastroenterology & its main clinical syndrome

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