Gastroenterology 2. Diagnostic methods for gastrointestinal diseases.
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Gastroenterology 2
Diagnostic methods for gastrointestinal diseases
Laboratory investigations
ESR: increased: inflammation, tumors (but can be normal)
Blood count – leukocytes: : inflammation– eosinophilia: helminthiasis, allergy– anemia (Hb, HCT): GI bleeding (manifest or
occult) Se Iron : bleeding, malabsorption, chr.infection
Laboratory investigations Liver tests:
– AST(GOT), ALT(GPT): cell damage– ALP, GGT, bilirubin: cholestasis– prothrombin time , se albumin : liver failure
Pancreas: amylase, lipase, functional tests
Fecal occult blood test (FOBT) Stool cultures for bacteria and parazites Urine: jaundice, uroinfection, kidney stone
Duodenal aspiration
Abdominal ultrasound
features
specific US methods– Doppler-ultrasound - for vascular lesions– US-guided biopsy– EUS- endoscopic ultrasound - endosonography
Abdominal ultrasound Liver
– echogenity, masses, cysts, bile ducts, veins Biliary tract
– gallstones (hyperechoic lesion with acoustic shadow), sludge, CBD stones, cholecystitis
Pancreas– acute pancreatitis, chr.pancreatitis, pseudocysts,
tumors Others
– ascites, organomegalies, lymph nodes, appendicitis, intraabdominal masses (tumor, abscess, cyst, inflammatory mass), kidneys
Radiology Plain abdominal X-ray
free air (upright position) gas/fluid levels within dilated loops calcifications
Upper GI barium radiography (single or double contrast studies)– esophagus (first examination in dysphagia)
contour, peristalsis, folds motility disorders, stenoses
Radiology Upper GI barium radiography
– stomach and duodenum peristalsis, emptying, shape, folds, retrogastric space perforation: with water-soluble contrast agent in case of GI hemorrhage: endoscopy
Barium study of the small bowel small bowel follow through study enteroclysis stenoses, polyps, mucosal alterations, ileitis terminalis
Radiology
Barium enema (double-contrast) (synonims: irrigoscopy, colonography)
mostly in cases of stenosis on endoscopy
Radiology - angiography
diagnosis of vascular diseases, obscure GI bleedings
therapeutic angiography is evolving
(chemoembolisation of tumors, occluding bleeding vessels, dilation of vessels)
Computer tomography
features
specific CT methods– spiral/helical CT– contrast agents (orally administered, iv.)– CT-guided biopsy– virtual colonoscopy
Computer tomography
Liver– masses (benign, malignant [primary or
metastatic neoplasms], hemangiomas, cysts, abscesses) , cirrhosis, ascites and other signs of portal hypertension, lymph nodes
Biliary tract– dilated bile ducts, imaging of CBD, distal
bile duct stones, CBD neoplasms
Computer tomography Pancreas - (the most useful method)
– neoplasms: diagnosis, staging– acute pancreatitis: extent of necrosis,
peripancreatic fluid collections, guided biopsies
– chr. pancreatitis: pseudocysts, calcifications Miscellaneous
– staging of gastrointestinal malignancies, intra-abdominal masses (abscess, inflammatory, tumors), invasion of adjacent structures
Magnetic resonance imaging
generally not superior to CT in abdominal diseases
sensitive very expensive special methods
– MR angiography– MRCP - magnetic resonance cholangio-
pancreatography
Endoscopy
features
diagnostic endoscopy– provides histological sampling (biopsy,
brush cytology) therapeutic endoscopy
Upper GI endoscopyEsophagogastroduodenoscopy (EGD)
Diagnostic GI bleeding refractory vomiting dysphagia, odynophagia gastroesophageal reflux ulcers suspicion of neoplasm (weight loss, etc.) surveillance of healing lesions surveillance of polyps, tumors
Upper GI endoscopy Therapeutic
treatment of variceal and nonvariceal GI bleeding
– injection technics, hemoclip, ligation, thermal technics (elelctrocoagulation, heat probe, laser, argon plasma)
removal of polyps, early neoplasms dilation of strictures placement of feeding gastrostomy tube removal of foreign bodies
Capsule endoscopy
Lower GI endoscopyColonoscopy, rectosigmoidoscopy, rectoscopy Diagnostic
– Bleedings (occult or hematochezia, iron deficiency)
– Chronic diarrhea– Suspicion of cancer– Suspicion of inflammatory bowel disease– Screening for cancer (altered bowel habits,
risk groups for colon cancer)
Lower GI endoscopyColonoscopy, rectosigmoidoscopy, rectoscopy
Therapeutic Removal of polyps, early cancers Dilation of stenoses Decompression
Endoscopic retrograde cholangio-pancreatography - ERCP Diagnostic
suspicion of choledocholithiasis unexplained jaundice and cholestasis acute gallstone pancreatitis some cases of chr. pancreatitis
Therapeutic endoscopic sphincterotomy - EST endoscopic biliary/pancreatic drainage endoscopic biliary/pancreatic stenting dilation of strictures endoscopic lithotripsy
Miscellaneous diagnostic methods Biopsies (US/CT-guided)- liver, pancreas, masses
Punctions - ascites, cysts– Percutaneous transhepatic cholangiography (PTC) or
drainage (PTD)
Laparoscopy Helicobacter pylori diagnostics
– stains, rapid urease-test, urease breath test (UBT)
24h pH monitoring Manometry (esophageal, rectal, Oddi-sphincter,
bowel)
Common abdominal syndromes
Gastroesophageal reflux disease - GERD History:
– Esophageal: heartburn, chest pain, regurgitation, acidic taste in mouth, dysphagia, odynophagia, Extraesophageal: chr.cough, asthma, noncardiac chest pain
Characteristics: increase in laying position
night symptoms
resolve after antacids Physical findings: Diagnosis: history, endoscopy, pH-
monitoring, barium swallow
Esophageal cancer
History: dysphagia, odynophagia, pain, vomiting, weight loss
Characteristics: older males, alcoholics, smokers
progressive dysphagia (solidsofterliquid)
vomiting just after meals Physical finding: general tumor signs Diagnosis: barium swallow, endoscopy
Peptic ulcer (duodenal, gastric) History: epigastric pain
Characteristics:– radiates to the back– duodenal: younger people, hyperacid symptoms,
relapsing disease, more symptoms in spring and fall, pain resolves after meals and recur after 2 hours, night pain, resolve using antacids
– gastric: older people, pain just after meals, weight loss– smokers– NSAID (aspirin) use
Peptic ulcer (duodenal, gastric)
Physical finding: epigastric/RUQ tenderness Diagnosis: endoscopy
Peptic ulcer - complications Bleeding: melena, hematemesis,
(rarely: hematochezia)
rectal digital examination Perforation: acute onset
very sharp pain (knife-like)
liver/splenic dullnes: absent
peritoneal signs: defence (guarding),
rebound tenderness, no bowel sounds
Dg: abdominal plain film
study with water-soluble contrast agent
Peptic ulcer - complications
Obstruction a. reversible
b. irreversible (scar)
History: vomiting of undigested food
fullness, pain
Physical signs: succussion splash
tenderness
Diagnosis: gastric emptying study (barium)
endoscopy
Gastric cancer History: epigastric pain, fullness, vomiting,
weight loss Characteristics: older people,
pain arise at meals
dull, progressive pain Physical findings:epigastric pain, epigastric mass
Virchow’s lymph node
general tumor signs
occult bleeding Diagnosis: endoscopy, US
Acute appendicitis History: first periumbilical, later ileocecal pain nausea subfebrility Characteristics: invariable first colicky, than steady pain Physical findings: ileocecal tenderness (McBurney’s point) ileocecal guarding rebound tenderness obturator sign: pain rotating the right hip psoas sign: pain raising against resistance the straightened right leg Diagnosis: physical examination, US, laboratory
Intestinal obstruction (ileus)1. Mechanical History: altered bowel habits, constipation,
fullness, meteorism, cramping pain, vomiting (bile, fecal material)
Characteristics: variable or progressive Physical finding: meteorism increased bowel sound splash signs of underlying disease Diagnosis: plain abdominal x-ray, CT searching for the cause
Intestinal obstruction (ileus)2. Paralytic History: signs of the underlying disease,
constipation, fullness, meteorism, cramping pain, vomiting
Physical finding: meteorism absent bowel sound splash signs of the underlying disease Diagnosis: plain abdominal x-ray
searching for the cause
Colorectal cancer History: altered bowel habits
bleeding (occult or manifest)
late: signs of obstruction
cramping pain
general tumor signs
positive family history
Physical finding:rectal digital examination late: mass, ileus Diagnosis: endoscopy, US, CT
Acute hepatitis
History: asymptomatic
after flu-like symptoms jaundice
anorexia, dyspepsia
RUQ pain Physical finding: jaundice
enlarged liver: smooth, soft, round, tender Diagnosis: liver tests, virus tests
Chronic hepatitis
History: symptoms: not characteristic
anorexia, dyspepsia
later: symptoms of cirrhosis Physical finding: enlarged liver (can be normal) Diagnosis: US, liver biopsy, serology
Liver cirrhosis History: alcohol consumption, chr. hepatitis
(HBV, HCV, HDV, HGV, autoimmune),
anorexia, dyspepsia, nausea
ascites, edemas, portal encephalopathy
jaundice, bleeding Physical findings:
first: enlarged liver micronodular: alcoholic
macronodular: chr. virus or autoimmune hepatitis- postnecrotic cirrhosis
end stage: small liver
Liver cirrhosis Physical findings: skin: palmar and plantar erythema spider naevi icterus (scratching) gynecomasty testicular atrophy signs of portal hypertension: ascites (transsudate) caput Medusae splenomegaly edema Diagnosis: US, liver biopsy, laboratory
Biliary colic History:pain after fatty meals
nausea, vomiting (often bile)
fullness, meteorism Characteristics: RUQ-pain, radiates to the back
(scapula, right shoulder)
mostly females Physical finding: RUQ tenderness Diagnosis: US
Acute cholecystitis History: like in biliary colic + fever Physical finding: Murphy’s sign Diagnosis: US, laboratory: signs of
inflammation
Choledocholithiasis History: like in biliary colic + obstr. jaundice Diagnosis: US, ERCP, CT
Acute pancreatitis History: gallstone disease, fatty meal, alcohol
epigastric pain
fullness, nausea, vomitus
fever
jaundice
hypotony, shock Characteristics: band-like, cramping pain
radiates to the back
Acute pancreatitis Physical findings: epigastric tenderness/guarding peritoneal signs signs of paralytic ileus (meteorism, no bowel
sounds) skin signs: Cullen’s sign-periumbilical ecchymoses Grey-Turner’s sign- lumbar ecchymoses Diagnosis: pancreatic enzimes, US, CT
Chronic pancreatitis History: cramping pain anorexia, dyspepsia, nausea, vomitus gallstone or alcohol consumption weight loss steatorrhea Characteristics: pain in the back increases after meals Physical finding: epigastric tenderness epigastric mass (pseudocyst) sometimes jaundice Diagnosis: plain abd. X-ray, US, CT, ERCP
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