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