Penyakit dan kelainan sistem gastroenterologi dan

pankreatobilier
(Diseases and Abnormalities in the
Gastroenterological and Pancreatobiliary System)

Marcellus Simadibrata K MD PhD SpPD KGEH FACG FINASIM

Department of Medical Education Faculty of Medicine University of Indonesia
Division Gastroenterology Department of Internal Medicine Faculty of Medicine University of
Indonesia

Lecture Module Gastrointestinal May 2013

Introduction

Gastrointestinal Diseases and Abnormalities:

Upper and Lower border: Treitz ligament
Diseases in upper GI tract: Syndrome of
dyspepsia, Gastroesophageal Reflux
Disease(GERD), dysphagia, peptic ulcer, upper
gastrointestinal bleeding(Hematemesis-Melena),
polyp and cancer of the gaster/duodenum,
cholangitis, bile duct Stone, pancreatitis.
Diseases in lower GI tract: diarrhea, irritable
bowel syndrome, collitis infective-non Infective,
Inflammatory Bowel Disease, polyp and cancer
of the colon, hemoroid
Buku ajar Ilmu Penyakit Dalam. PIP Penyakit dalam jilid 1. 2005

Syndrome of Dyspepsia

Definition : persistent or recurrent upper abdominal pain

or discomfort characterized by postprandial fullness,
early satiety, nausea, and bloating.
Classification: Functional and organic , or ulcer and non
ulcer(NUD)
Functional: dysmotility like, ulcer like, non-specific,
(reflux like). Functional: no organic diseases.
Organic(with x-ray or endoscopy): peptic ulcer, cancer,
severe gastritis-duodenitis.

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

PATHOGENESIS of Gastric mucosal Damage

Figure1. The Balance between aggressive and defensive factors

Aggressive factors
Gastric acid
Pepsin
Bile reflux
Nicotine
NSAID
Corticosteroid
Helicobacter pylori
Free radicals
Stress

Defensive factors
Mucosal blood flow
Epithelial cell surface
Prostaglandin
Phospholipid/surfactan
Mucus
Bicarbonate
Motility
Mucosal impermeability to
H+ ion
Intracellular pH regulation
Growth factor

cited from Daldiyono & Shiessel R et.al.

Clinical features in syndrome

dyspepsia

NUD:
1. ulcerlike: dominant epigastric pain, relieved by
antacids or food
2. dysmotility like: epigastric discomfort aggravated
by food or associated with early satiety, fullness,
nausea, retching, vomiting, or bloating.
3. nonspecific: symptoms does not fit the other
categories
Ulcer: the same with NUD

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

Findings and diagnostic findings in

syndrome dyspepsia

routine: blood, stool, amylase-lypase , liver function test .

upper gastrointestinal endoscopy: if age > 45 years or
NSAID consumption or alarm symptoms: weight
loss,hemorrhage, dysphagia, vomiting, jaundice. Biopsy
for histopathological or helicobacter pylori.
Double contrast upper gastrointestinal barium
radiography
Gastric scintigraphy: gastric gastroparesis/motility
Helicobacter pylori serology examination.
Ultrasound/CT-scan: to exclude gallbladder/biliary
stone/malignancies, pancreatitis.

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

Management of Syndrome Dyspepsia:

Avoid/stop -decrease the aggravating/agresive factors,

increase the defensive factors.
Young patients < 45 years, no NSAID consumer nor
alarm symptoms : empiric therapy 2-4 weeks:
Ulcer like: antacids or h2 receptor antagonist or proton
pump inhibitor.
Dysmotility like: prokinetic or h2 receptor antagonist.
Nonspecific: antifatulent antacids,
simethicone, antianxiety-depression.
Peptic ulcer: H2RA or PPI with/without cytoprotector
Upper GI malignancies: operation.

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

GASTROESOPHAGEAL REFLUX DISEASE

(GERD)

DEFINITION: a pathologic consequences of the

effortless movement of gastric contents to the
esophagus, including symptoms or signs referable to the
esophagus, pharynx, larynx, and respiratory tract.
CLINICAL FEATURES: Heartburn, substernal chest
discomfort, regurgitation bitter or acid-tasting liquid,
water brash or hypersalivary, solid dysphagia,
odynophagia, oropharynx damage(sorethroat, erache,
gingivitis, poor dentition, and globus), reflux damage of
the larynx and respiratory tract (hoarseness, wheezing,
bronchitis, asthma, pneumonia).
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

Pathophysiology of GERD

Spectrum Of Endoscopic
Findings with GERD

Normal esophagus

Grade 3 esophagitis

Grade 4 esophagitis

Barretts esophagus

MANAGEMENT of GERD

Lifestyle modification: Head elevation, stop smoking/alcohol, reduce

meal size and intake of fat/carminative/chocolate/coffee, carbonated
beverages, tomato juice, citrus products, stop medications reducing
LES pressure (anticholinergics, theophylline etc.)
Medication therapy:
- Acid suppressive drugs:
1. Proton pump inhibitor(PPI)( omeprazole, lansoprazole,
rabeprazole, pantoprazole, esomeprazole): drug of choice
2. H2 receptor antagonists(cimetidine, ranitidine, famotidine,
nizatidine): mild-moderate
3. Liquid Antacids: good for mild
- Prokinetics agents: metoclopramide, domperidone, cisapride
Surgical treatment.
Endoscopic fundoplication.

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

PEPTIC ULCER DISEASE(PUD)1

DEFINITION:
PUD Mucosal break gaster and duodenum,
diameter more than 0,5 cm.
Refractory ulcer duodenal ulcer 8 weeks
therapy ineffective or gastric ulcer lack response
to 12 weeks treatment.
PATHOGENESIS: Imbalance, aggressive factors
>>> defensive factors(see dyspepsia).

Simadibrata M. Penatalaksanaan tukak peptik MKI 2007

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

CLINICAL FEATURES of PUD

Abdominal pain 94%: epigastric in location, does not

radiate, occurs 2-3 hours postprandially, and
relieved by food or antacids. Some time awakens
the patient between midnight and 3 AM.
Some patients have no symptoms
Complications: hemorrhage(melena)(15%),
perforation(7%), penetration, and obstruction(2%).

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

FINDINGS ON DIAGNOSTIC
TESTING of PUD

routine blood(Hb, leukocyte) & stool(occult blood test)

Upper gastrointestinal barium radiography: gastric &
duodenal ulcer
Upper gastrointestinal endoscopy: gastric & duodenal
ulcer, biopsy for histopathological examination:
benign/malignant disease, Helicobacter pylori infection
Helicobacter pylori testing: serology, culture/CLO
test/histopathology examination from upper GI
endoscopy examination, C-Urea Breath test, Stools
H.pylori antigen
Serum gastrin and gastric acid secretion testing:
hypergastrinemia in gastrinoma
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

MANAGEMENT of PUD-1
Non pharmacological management:
- stomach diet,
- avoid/stop aggressive factors: stress etc.
Pharmacological management:
- H2 receptor antagonist.
- Proton pump inhibitors.
- Cytoprotective Agents: Sucralfate, Misoprostol,
Bismuth subsalicylate, Tephrenone and
Rebamipide

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

Helicobacter pylori Eradication(KSHPI)

Tripple therapy(1 or 2 weeks):

1.

Quadruppel therapy(1 or 2 weeks):

1. If

PPI+Amoksisilin+Klaritromisin
2. PPI+Metronidazol+Klaritromisin
3. PPI+Metronidazol+Tetrasiklin (alergy to chlarithromisin)

fail of therapy combination 3 drugs:

Bismuth+PPI+Amoksisilin+Klaritromisin
Bismuth+PPI+Metronidazol+Klaritromisin
2. Hight resistency areas:
PPI+Bismuth+Tetrasiklin+Metronidazol

PPI 2 x/d; Omeprazol/Esomeprazol 20 mg,

Lansoprazol 30 mg, Pantoprazol 40 mg, Rabeprazol 10 mg.
Amoksisilin: 2 x 1000 mg/d, Klaritromisin 2 x 500 mg/d, Metronidazol 3 x
500 mg/d, Tetrasiklin 4 x 250 mg/d, Bismuth 4 x 120 mg/d.

KSHPI, Konsensus infeksi Helicobacter pylori di Indonesia 2003

DYSPHAGIA

DEFINITION:
- Dysphagia sensation of food being hindered in
its passage from the mouth to the stomach.
- Odynophagia pain on swallowing.
- Globus sensation perception of a lump,
tightness, or fullness in the throat that is
temporariloy relieved by swallowing.
CATEGORY: Dysphagia divided into:
1. Illnesses involving oral preparation, oral transfer,
or pharyngeal phases of swallowing
2. conditions involving dysfunction
of the
esophageal phase
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

Table 1. Causes of dysphagia

Oropharyngeal dysphagia
Neuromuscular diseases
Cerebrovascular accident
Parkinsons disease
Wilsons disease
Amyotrophic lateral sclerosis
Brain stem tumors
Bulbar poliomyelitis
Peripheral neuropathy
Myasthenia gravis
Muscular dystrophies
Polymyositis
Metabolic myopathy
Amyloidosis
Systemic lupus erythemathosus
Local mechanical lesions
Inflammation(pharyngitis, abscess, tuberculosis, radiation, syphilis)
Neoplasm
Congenital webs
Plummer-vinson syndrome
Extrinsic compression(thyromegaly, cervical spine hyperostosis, adenopathy)
Oropharyngealk resection
Upper esophageal sphincter(UES) disorders
Hypertensive UES
Hypotensive UES
Abnormal UES relaxation(cricopharyngeal achalasia, central nervous system, lymphoma,
Oculopharyngeal muscular dystrophy, cricopharyngeal bar, Zenkers diverticuum, familial
Dysautonomia)Esophageal dysphagia
Motility disorders
Achalasia
Scleroderma
Diffuse esophageal spasm
Nutcracker esophagus
Hypertensive lower esophageal sphincter
Nonspecific esophageal dysmotility
Other rheumatologic conditions
Chagas disease
Intrinsic mechanical lesions
Benign stricture(peptic, lye, radiation)
Schatzkis ring
Carcinoma
Esophageal webs
Esophageal diverticula
Benign tumors
Foreign bodies
Extrinsic mechanical lesions
Vascular compression
Mediastinal abnormalities
Cervical osteoarthritis

DIAGNOSIS of Dysphagia

History: distinguish oropharyngeal / esophageal in

location and if it is structural or neuromuscular in origin.
Etc.
Physical examination: The head and neck sensory
and motor function of the cranial nerves, masses,
adenopathy, or spinal deformity. Examine systemic
disease.
Additional testing: Barium swallow radiography, Upper
endoscopy and biopsy, UES manometry.

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

Management of Dysphagia

The management depend on the cause.

Neuromuscular diseasemyotomy(surgical)
Benign stricturesdilatation by bougienage
Early malignancies surgically resected
Unresectable malignancies dilatation, cautery, laser or stenting
Achalasiamedications(calcium channel antagonists), botulinum
toxin injection into the LES, by endoscopic dilation, and by
surgical myotomy.
Other primary esophageal dysmotilities respond to nitrates,
calcium channel antagonist, surgical myotomy.

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

ACHALASIA-1

The most easily recognized & best-defined motor

disorder of the esophagus
Incidence 1 per 100.000 population per year in US.
Classification: Primary & Secondary.
Neuropathology: LES failure to relax completely &
aperistalsis smooth muscle esophagus damage
innervation loss of ganglion cells within
myenteric(Auerbach) plexus, degeneration vagus
nerve & degeneration dorsal motor nucleus vagus.

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

ACHALASIA-2

Clinical manifestation: dysphagia(100% solid

& half liquid), regurgitation, chest pain, weight
loss& aspiration pneumonia.
Esophagogram: esophageal dilatation with
distal stenosis bird beak(paruh burung)/rat
tail(ekor tikus).
Esophagoscopy: esophageal dilatation /atony
with food residue/saliva.
Treatment: Dilatation(bougie, pneumaticballoon), Botulinum toxin injection, Operation.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

UPPER GASTROINTESTINAL
BLEEDING(HEMATEMESIS-MELENA)

DEFINITION: Upper gastrointestinal bleeding/

hematemesis melena refers to bleeding source from
the upper gi tract. The blood in stool tarry stools,
the blood vomitingblack tarry vomiting
EPIDEMIOLOGY:
The frequent cause of upper gi bleeding in
Indonesia is rupture of esophageal varices.
The frequent cause of upper gi bleeding in Europe is
peptic ulcer.

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

Bad Predictor in upper

gastrointestinal bleeding

Age > 60 years

Other comorbid
Hypotension or shock
Coagulopathy
Bleeding onset in hospital
Transfusion requirement > 6 unit
Fresh bleeding from stomach
Recurrens bleeding from the same lesion

Triadapafilopoulos G. Aliment Pharmacol Ther 2005;22(suppl.3): 53-8

WORKUP/DIAGNOSIS of Hematemesis
Melena
Resuscitation

History
Physical examination
Upper gi endoscoopy
Scintigraphy and angiography: the rate of blood loss
must exceed 0.5 ml per minute.
Other radiographic studies: for aortoenteric fistula
abdominal computed tomographic or magnetic
resonance imaging studies

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

MANAGEMENT of Hematemesis Melena

Blood Transfusion
Medications: PUD/gastritis: H2RA, or PPI; varices or portal
gastropathy: vasopressin / terlipressin / somatostatin or
octreotide . Angiodysplasia: intravenous or oral estrogens with
or without progesterone.
Therapeutic endoscopy: thermal and nonthermal methods.
Emergency upper endoscopy ; esophageal banding or
sclerotherapy.
Mechanical compression: ballon tamponade/SenstakenBlakemore tube or Linton-nachlas , then followed by
sclerotherapy or ligation.
Therapeutic angiography
Surgery:if endoscopy fails

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

LOWER GASTROINTESTINAL
BLEEDING

DEFINITION: Lower gastrointestinal

bleeding refers to bleeding source from the
lower gi tract. The blood in stool red fresh
bloody stools.

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

ETIOLOGY/CAUSES/DIFFERENTIAL DIAGNOSIS
LOWER GI BlEEDING

Diverticulosis
Angiodysplasias
Hemorrhoids
Anal fissures
Neoplasms
Inflammatory bowel disease
Ischemic colitis
Infectious colitis
Radiation induced colitis
Meckels diverticulum
Intussusception
Aortoenteric fistula
Solitary rectal ulcera
NSAID-induced cecal ulcers
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

DIAGNOSIS/WORKUP

Resuscitation: correction of volume deficits &

stabilization of hemodynamic variables. If
suspected upper gi bleeding ngt, Laboratory
studies
History & Physical examination: GI diseases such
as IBD, malignancy(weight loss, anorexia,
lymphadenopathy, or palpable masses) etc
Additional testing: Endoscopy, Scintigraphy &
angiography, Other radiologic studies(Barium
enema).
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

MANAGEMENT LOWER GI
BLEEDING-1

Medications.
Therapeutic endoscopy.
Therapeutic angiography.
Surgery

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

ACUTE ABDOMEN

DEFINITION: Acute abdomen refers to any

acute intra & extra abdominal disease
processes. Many cases require urgent
surgical management, although some can be
managed nonsurgically.

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

ETIOLOGY/CAUSES/DIFFERENTIAL DIAGNOSIS OF ACUTE

ABDOMEN

Gastrointestinal
Appendisitis
Perforated peptic ulcer
Intestinal ischemia
Diverticulitis
Inflammatory bowel disease
Meckels diverticulitis
Pancreaticobiliary tract, liver, spleen
Acute pancreatitis
Calculous cholecystitis
Acalculous cholecystitis
Acute cholangitis
Hepatic abscess
Ruptured hepatic tumor
Splenic rupture
Urinary tract
Renal/ureteral stone
Gynecologic
Ectopic pregnancy
Tuboovarian abscess
Ovarian torsion
Uterine rupture
Ruptured ovarian cyst or follicle
Retroperitoneum
Abdominal aortic aneurysm
Supradiaphragmatic
Pneumothorax
Pulmonary embolus
Acute pericarditis
Empyema

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

WORKUP/DIAGNOSIS ACUTE ABDOMEN-1

History:
Acute appendicitis: periumbilical pain, low-grade fever, anorexia
with/without vomiting followed by movement of the pain into the right
lower quadrant McBurneys point.
Constipation: obstructive conditions, inflammatory disorders produce
ileus.
Watery diarrhea: gastroenteritis,
Bloody diarrhea: infectious colitis, inflammatory bowel disease,
mesenterial ischemia.
Jaundice: hepatic and pancreaticobiliary disease, sepsis.
Urinary abnormality : urologic disease.
Physical examination:
Appendicitis acute: local peritonitis at McBurneys point, psoas sign(+).
Perforation: general/local peritonitis, disappear of liver percussion
dullness.
Bruits mesenteric thrombosis.
Ectopic pregnancyunilateral adnexal mass with blue cervical
discoloration.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

WORKUP/DIAGNOSIS ACUTE ABDOMEN2

Initial studies:
Blood testing: anemia, leukocytes, or leukopenia, serum
electrolytes, blood urea nitrogen, and creatinine,
pregnancy test,
Peritonitis abdominal radiographs(3 positions
abdominal xray)
Gas in the biliary tree fistula or cholangitis. Ileus
diffusely dilated loops of the small intestine & colon.
Free subdiaphragmatic air 75% patients with ulcer
perforation.
Decision to operate immediately
Imaging studies: CT-scan, ERCP/MRCP

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

MANAGEMENT OF ACUTE ABDOMEN

Urgent surgery
Conservative management

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

DIARRHEA

DEFINITION: Stool soft or watery with a daily

stool weight of > 200 g(250g). Frequency
more than 3 times/day

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

CAUSES/DIFFERENTIAL DIAGNOSIS OF DIARRHEA

High output osmotic

Nonabsorbed solutes
Saline and phosphate laxatives
Sorbitol, fructose, lactulose
Disaccharidase deficiency
Lactase deficiency
Isomaltase-sucrase deficiency
Trehalase deficiency
Small intestinal mucosal disease
Celiac spure
Tropical sprue
Viral gastroenteritis
Whipples disease
Amyloidosis
Intestinal ischemia
Lymphoma
Giardiasis
Pancreatic insuffciency
Chronic pancreatitis
Pancreatic carcinoma
Cystic fibrosis
Reduced intestinal surface area
Small intestinal resection
Enteric fistulae
Jejunoileal bypass
Bile salt malabsorption
Bacterial overgrowth
Ileal resection
Crohns disease
Defective transport
Congenital chloridorrhea
High-output secretory
Laxatives
Bisacodyl
Phenolphthalein
Ricinoleic acid
Dioctyl sodium sulfosuccinate
Bacterial toxins
Vibrio cholerae
Toxigenic Eschericia coli
Clostridium perfringens
Hormonally induced
Vasoactive intestinal polypeptide
Serotonin
Calcitonin
Glucagon
Gastrin
Substance P
Prostaglandins

Defective neural control

Diabetic diarrhea
Bile acid diarrhea
Ileal resection
Crohns disease
Bacterial overgrowth
Post cholecystectomy
Mucosal inflammation
Collagenous colitis
Lymphocytic c olitis
Villous adenoma
High output injury
Inflammatory bowel disease
Crohns disease
Ulcerative colitis
Acute infections
Viruses(rotavirus, Norwalk agent)
Parasites(Giardia, Cryptosporidium,
Cyclospora)
E.coli
Shigella
Salmonella
Campylobacter
Yersinia enterocolitica
Entamoeba histolytica(amebiasis)
Chronic infections
E.histolytica(amebiasis)
Clostridium difficile
Ischemia
Atherosclerosis
Vasculitis
Normal output
Motility disorders
Irritable bowel syndrome
Endocrinopathies
Hyperthyroidism
Proctitis
Ulcerative proctitis
Infectious proctitis
Fecal incontinence
Surgical and obstetrical trauma
Hemorrhoids
Anal fissures
Perianal fistulae
Anal neuropathy(diabetes

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

CLASSIFICATION

Time: acute less than 15 days chronic more

than 15 days
Organic diseases: Organic and functional
Infective/infectious causes: Infective/infectious and
non-infective/infectious
Stool: soft, watery, bloody or steatorrhea, bloody ,
nonsteatorrhea nonbloody
Pathomechanism: osmotic, secretory, increased
motility, mucosal inflammation,
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

DIAGNOSIS OF DIARRHEA-1

History:

Duration of diarrhea, recent travel, sexual practices, ingestion

of well water and poorly cooked food and shellfish, and
exposure to high-risk persons in day care centers, hospitals,
mental institutions, and nursing homes.
The characteristics of the diarrhea causative organism.
Watery diarrhea+nausea, little paintoxin producing bacteria.
Invasive bacteria pain, bloody diarrhea.
Viruses watery diarrhea, pain significant, fever, mildmoderate vomiting.
Homosexual men, prostitutes, iv drug abusers diarrhea
through oral-fecal transfer.
Antibiotic associated colitis recent antibiotic use.
Recent medications: antacids containing magnesium,
antirrhytmias, antihypertensives, diuretics, central nervous
system drugs, antiarthritis, cholesterol lowereing medications
and theophylline.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

DIAGNOSIS OF DIARRHEA-2 Physical

Examination
Abdominal tumor/mass, dehydration, fever etc.

Hypotension, decreased skin turgor, dry mucous membranes

dehydration need intravenous hydration.
Emaciation, cheilosis and glossitis severe malabsorption.
Dermatitis herpetiformis celiac sprue,
Pyoderma gangrenosusm inflammatory bowel disease,
Sclerodactily scleroderma.
Arthritis inflammatory bowel disease or Whipples disease.
Resting tachycardia hyperthyroidism, pulmonic stenosis and tricuspid
regurgitation carcinoid syndrome.
Peripheral or autonomic neuropathy visceral neuropathy in diabetes
and intestinal pseudo-obstruction.
Neuropsychiatric findings Whipples disease.
Abdominal mass malignancy, Crohns disease, diverticulitis.
Localized abdominal tenderness inflammatory condition.
A digital rectal examination perianal disease with Crohns disease,
reduced sphincter tone incontinence.
Occult or gross fecal blood infectious, inflammatory and neoplastic
conditions.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

DIAGNOSIS OF DIARRHEA-3 - Acute diarrhea

Routine stool examination.

Complicated and prolonged infection, unresponsive to
supportive care routinestool culture for Salmoneella,
shigella, or Campylobacter organisms.
Special culture techniques Yersinia, Plesiomonas
organisms and enterohemorrhagic E.coli.
Stool samples for parasitic diseaseova & parasites:
Giardia, Cryptosporidium, E.histolytica or
Strongyloidesorganisms.
Recent antibiotic use Stool C.difficile culture and toxin
determination.
20-40% acute infectious diarrhea remain undiagnosed
despite laboratory evaluation.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

DIAGNOSIS OF DIARRHEA-4- Chronic diarrhea

Stool examination for leukocytes, fat (Sudan stain) for fat

malabsorption, parasites and stool culture.
Antibiotic use culture C.difficile. Serum electrolyte
Erythrocyte sedimentation rate systemic inflammatory
disease.
Serum albumin and globulin reduced malabsorption,
malnutrition, or protein losing enteropathy.
Additional blood testsfor malnutrition: carotene, iron,
folate, vitamin B12, cholesterol, alkaline phosphatase
and prothrombin time.
Flexibel sigmoidoscopy exclude proctitis,
pseudomembranes and melanosis coli due to laxative
abuse.
Biopsy for normal appearance microscopic and
collagenous colitis or irritable bowel syndrome.
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

MANAGEMENT OF DIARRHEA

Intravenous resuscitation
Agents for mild diarrhea: antidiarrheal, bismuth subsalicylate,
diphenoxylate, codeine.
Antibiotics for acute infectious diarrhea
Therapy for osmotic diarrhea: carbohydrate malabsorption
lactase deficiency or fructose or sorbitol intolerance dietary
modification, lactase supplements
Therapy of secretory diarrhea somatostatin analog(octreotide),
parenteral calcitonin, indomethacine.
Therapy for inflammatory diarrhea anti-inflammatory
drugs(aminosalicylate and corticosteroid. Refractory cases
azathioprine, 6mercaptourine, methotrexate.

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

Polyp and Cancer of the

gaster/duodenum

Definition: tumor of the gaster/duodenum,

benign and malignant(cancer)
Management: polypectomy per endoscopic
or operation

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

Cholangitis

Definition: Infection of the common bile duct due to

obstruction like biliary stone or cholangiocarcinoma
or papillary tumor.
Management:
- Antibiotic
- ERCP diagnostic and therapetic(sphincterotomy +
stone extraction or stenting)
- Operative: laparoscopic cholecystectomy & stone
extraction or laparotomy biliodigestive procedure

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

Bile duct Stone

Definition: Stone of the common bile duct.

Management:
ERCP or operation

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

Pancreatitis

Definition: Inflammation or infection of the

pancreas
Classification: Acute and Chronic
Management:
1. Conservative: Fasting, total parenteral
nutrition, antibiotics, octreotide/somatostatin,
anti TNF).
2. Surgery

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

Acute pancreatitis with pancreatic enlargement

& Peripancreatic edema & pseudocysts

Diagnosis of Acute
Pancreatitis
Clinical Features: abdominal pain, vomiting
Elevation of plasma amylase - lipase recommendation grade A
3 or 4 x normal (must not always rely on this value)
Plain radiograph
Abdominal Ultrasonography: pancreatic swelling(25-50%
patients), CBD/gall bladder stones, dilatation of the CBD
Abdominal CT-scan(recommendation grade C)
Abdominal Magnetic Resonance Imaging(MRI)
CBD stones: ERCP & MRCP

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

Severity of Acute
pancreatitis

Mild ( Edema type ): fat necrosis of the

pancreatic superficial & interstitial edema
Severe( Hemorrhagic-Necrotic type): diffuse
fat necrosis of pancreatic superficial and
parenchymal. Necrotic and bleeding of the
pancreatic parenchymal.

Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003

Etiologic factor & Pathogenesis in Acute Pancreatitis

Etiologic factor(Biliary, alcoholism, unknown etc)
Initial process(bile reflux, duodenal refux etc)
Initial damage of the pancreas(edema, vascular injury, acinar pancreatic duct rupture)
Digestive enzyme activation
Trypsin
Phospholipase A
Elastase
Chymotrypsin
Kallikrein

Lypase

Autodigestive
Pancreatic necrosis

Lankisch.Acute Pancreatitis. Springer Verlag 1987

Irritable Bowel Syndrome

Definition: Symptoms of lower gastrointestinal like

diarrhea, constipation or combination with abdominal
cramps/pain. No organic abnormality found in
colonoscopy.
Pathogenesis: stress, hypersensitivity, abnormal
serotonin, abnormal motility etc.
Management:
- Diet rich of fibre
- Anti Anxiety-Depression
- Constipation: Prokinetic , 5 HT 4 agonist
- Diarrhea: Antispasmodic, anticholinergic
Yamada T et.al. Textbook of Gastroenterology. 4th ed. Volume one.2003