This document provides an overview of common gastrointestinal (GI) problems encountered by 4th year medical students, including gastroesophageal reflux disease, peptic ulcer disease, acute and chronic diarrhea, constipation, and irritable bowel syndrome. It also discusses acute abdominal pain, including etiology, classification, patterns, and localization. Specific conditions causing acute abdominal pain like biliary colic, acute pancreatitis, and perforated ulcers are described. Dyspepsia, its prevalence, causes, and management are also summarized.

4. Etiology of acute abdominal pain

6. Classification of pain by the rate of development

7. Patterns of acute abdominal pain Subside spontaneously with time: gastroenteritis colicky progressive Abrupt:ruptured aneurysm

8. 1 2 1 2 3 3 Visceral pain localization 1. midline epigastrium = foregut (T7-T9) 2. periumbilical region = midgut (T9-T11) 3. lower midabdomen = hindgut (T11-L1)

21. Epigastric Pain Mild, long duration or recurrent “ Dyspepsia” Acute-Severe Abdominal signs, Ileus? Loss liver dullness? Jaundice? CBC, amylase, AST/ALT, ALP, film abdomen series Amylase> 3 times Abnormal AST/ALT +/- ALP Free air Normal Acute pancreatitis Biliary colic PU perforation Bowel habit change? No Yes IBS, CA colon Rx as PU or Functional dyspepsia No response or recurrent Alarm feature? No Yes Gastroscopy Admit U/S Surgery

23. RUQ Pain Afebrile Febrile Hepatomegaly? Yes No Tender on percussion or point of tenderness? Yes No R/O liver abscess U/S Liver abscess Negative Systemic infection Jaundice No jaundice U/S U/S Ac.Cholangitis Ac.Cholecystitis Confirm Negative Confirm Biliary colic? Yes LFT, U/S No Hepatomegaly? Yes No U/S, LFT Liver abscess, HCC, other liver mass, hepatitis, congestion PU or NUD IBS, CA colon, Rt. UC

24. Acute Calculous Cholecystitis

26. Murphy’s Sign  Sensitivity 65%, Specificity 87% Trowbridge RL, et al. JAMA 2003; 289: 80-86

27. US Finding of Acute Cholecystitis

28. Acute cholecystitis Admission, supportive care iv ATB 12-24 hr Determine surgical risk Low risk High risk Clinical Improvement Clinical Deterioration Clinical Improvement Clinical Deterioration Elective LC Within 72 hr Emergency LC Percutaneous Cholecystostomy D/C Non-surgical GS therapy Delayed elective LC 6-8 wk

34. Symptoms & Signs of Liver Abscess NR 10 9 Ascites MLA PLA ALA 26 21-48 14-27 Jaundice 47 35-62 33-77 Abd tenderness NR 10 11 Peritonitis Signs 76 52-85 62-87 Hepatomegaly Hx dysentery RUQ pain Abd pain Fever Symptoms NR 0-11 10-42 24 45-48 47-60 44 52-58 86-100 100 42-86 51-84 Frequency (%)

36. RUQ Pain Afebrile Febrile Hepatomegaly? Yes No Tender on percussion or point of tenderness? Yes No R/O liver abscess U/S Liver abscess Negative Systemic infection Jaundice No jaundice U/S U/S Ac.Cholangitis Ac.Cholecystitis Confirm Negative Confirm Biliary colic? Yes LFT, U/S No Hepatomegaly? Yes No U/S, LFT Liver abscess, HCC, other liver mass, hepatitis, congestion PU or NUD IBS, CA colon, Rt. UC

40. Prevalence of dyspepsia in general population 1 Knill-Jones 1991, 2 Talley 1996, 3 Penston 1996 4 Kang 1985, 5 Kachintorn 1999, 6 Katelaris 1992

41. Etiology of dyspepsia (endoscopically) NUD 77% NUD 61.9% Misc 1.4% Misc 9.8% GU 11.1% GU 11.3% DU 8.2% DU 10.1% CA 2.1% CA 2.2% ESO 4.9% Stomach Research Group 1999 Siriraj Hospital 1997 N = 4222 N = 2926

43. A survey of etiology of dyspepsia and prevalence of H.pylori infection in every regions of Thailand Kachintorn U, et al.1999 n = 1,171 Overall H.pylori + 52.52%

46. Dyspepsia NUD PUD or HBD PUD HBD Pain occurring before meal or when hungry Nocturnal epigastric pain Anemia … .of epigastric pain + + - - + - + -

48. Dyspepsia R/O typical biliary pain, IBS Alarm features Life style modification (LSM) Education + symptomatic Antisecretory and/or prokinetic for 2-4 wks Consider appropriate Investigation Success continue till 6-8 wks No recurrence recurrence failure Alarm features Endoscopy + Ultrasound Approach to dyspeptic patient * At least 4 wks duration * uninvestigated

51. First-line management in uninvestigated patients Predominant pain or discomfort Predominant heartburn =GERD Ulcer-like Dysmotility-like + Dysmotility symptoms - Dysmotility symptoms Potent acid suppression Prokinetic Potent acid suppression + Hp eradication Investigate unresponsive patients

59. Dyspepsia R/O typical biliary pain, IBS Alarm features Life style modification (LSM) Education + symptomatic Antisecretory and/or prokinetic for 2-4 wks Consider appropriate Investigation Success continue till 6-8 wks No recurrence recurrence failure Alarm features Endoscopy + Ultrasound Approach to dyspeptic patient * At least 4 wks duration * uninvestigated

60. Peptic ulcer disease (PUD)

61. Gastric ulcer

64. Gastroduodenal Mucosal Integrity is Determined by Protective (“defensive”) and Damaging (“aggressive”) Factors HCO 2 Mucus Blood Flow Growth Factors Cell Renewal PGs Protective Damaging Hypoxia H + Pepsins Smoking Ethanol Bile acids Ischemia NSAIDs H.pylori

65. Peptic Ulcers are Caused by Increased Aggressive Factors and/or decreased defensive factors Increased Aggressive Factors And/or Decreased Defensive Factors Mucosal Damage Ulcer

66. Helicobacter pylori

72. Evolving Management of PU Treat with single Anti-ulcer Test and Rx for Hp Treat with single Anti-ulcer 4-6 wks Symptoms remain Symptoms- free evaluate maintenance Confirm cure Obviates need for maintenance 8-12 wks Evaluate for healing DU GU healed maintenance

92. Algorithm for Treatment of Temporary Constipation Assess speed of action needed and longer term management Seek reason Effect within a week Lennard JE. Gastrointestinal Disease 1998:174 Effect within 2-3 D Effect within 24 hr Single or few doses Bulk laxative (Psyllium, ispaghula) Osmotic laxative (Mg, lactulose) Continued treatment Continued treatment Stimulant laxative (Senna, bisacodyl)

93. Initial visit for chronic constipation Hx and PE Primary cause of constipation? Assess severity BE, sigmoidoscopy No mechanical obstruction Predominantly infrequency Redefine symptoms Predominantly straning Evaluate and treat Therapeutic trial of fiber Yes Mild Failure No Algorithm for Evaluation of Chronic Severe Constipation Severe Campion MC & Orr WC. Evolving Concepts in Gastrointestinal Motility 1996

94. Acute Diarrhea

97. Drugs commonly associated with diarrhea

101. Stool leukocyte

104. Recommended antibiotics in acute diarrhea Working party report, WCOG 2002 Fluoroquinolone: norfloaxacin 400 mg, ciprofloxacin 500 mg, b.i.d.

109. Patterns of Laboratory Tests in Types of Acute Hepatic Injury X-times : URI-upper reference limit