gastrointestinal diseases

• Symptoms of oral cancer

  • Solitary ulcer without precipitant, e.g. local trauma
  • Solitary white patch ('leukoplakia') which fails to wipe off
  • Solitary red patch, Fixed lump
  • Lip numbness in absence of trauma or infection
  • Trismus (painful/difficult mouth opening)
  • Cervical lymphadenopathy
• Common causes of oral ulceration

  • Aphthous ulcer: (idiopathic causes)
  • Infection: Fungal candidiasis; Bacterial (syphilis, tuberculosis); Viral (herpes simplex, HIV)
  • Gastrointestinal diseases: Crohn's disease
  • Neoplasia: Carcinoma: Oral Squamous carcinoma (OSCC); Kaposi's sarcoma ; Leukaemia
  • Dermatological conditions: lichen planus, lichenoid drug reaction, Stevens-Johnson syndrome; erythema multiforme, Systemic diseases, Behçet's syndrome, Systemic lupus erythematosus
  • Drugs: NSAIDs, Nicorandil, methotrexate, penicillamine, losartan, ACE inhibitors, Cytotoxic drugs
• Recurrent Aphthous Ulceration (RAU)

  They are superficial painful shallow ulcers occurring in any part of the mouth. Recurrent ulcers afflict up to 30% of the population, idiopathic, common in women prior to menstruation, can become recurrent. The age of onset usually in adolescents and early adulthood.
• Types of RAU

  • Minor
  • Major
  • Herpetiform
• Management of RAU

  • Topical corticosteroids (such as 0.1% triamcinolone in Orabase)
  • Choline salicylate (8.7%) gel for pain relief
  • Local anaesthetic mouthwashes for pain relief
• Causes of vomiting

  • Alcoholism
  • Drugs: NSAID, Opiates, Digoxin, antibiotics, cytotoxins
  • Infection: hepatitis, gastroenteritis, UTI
  • Metabolic: diabetic ketoacidosis, Addison disease, cyclical vomiting syndrome
  • Psychogenic: occurs as a result of an emotional or psychic disturbance
  • CNS disorders: vestibular neuronitis, migraine, raised intracranial pressure, meningitis
  • Gastroduodenal: peptic ulcer disease, gastric cancer, gastroparesis
  • Renal: Uremia
  • The acute abdomen: appendicitis, cholecystitis, pancreatitis, intestinal obstruction
• Haematemesis

  Vomiting of blood, fresh blood (red in colour) with clots: rapid and profuse bleeding, black ('coffee grounds') vomitus : when bleeding is less severe
• Associated symptoms of haematemesis

  • Syncope may occur due to hypotension
  • Symptoms of anaemia suggest chronic bleeding
• Melaena

  Defined as the passage of black, tarry stools containing altered blood. The characteristic colour and smell are the result of the action of digestive enzymes and of bacteria upon haemoglobin.
• Causes of melaena

  • Bleeding from the upper gastrointestinal tract
  • Less commonly: haemorrhage from the right side of the colon
  • Severe acute upper gastrointestinal bleeding can sometimes cause maroon or bright red stool
• Causes of gastrointestinal haemorrhage

  • Peptic ulcer (35-50%)
  • Esophagitis (10%)
  • Vascular malformation (5%)
  • Aorto-duodenal fistula (0.2%)
  • Varices (2-9%)
  • Mallory-Weiss tear (5%)
  • Cancer of stomach or esophagus (2%)
  • Gastric erosions (10-20%)
  • Oesophagitis (10%)
• Acute upper gastrointestinal haemorrhage

  This is the most common gastrointestinal emergency, Haematemesis is red with clots when bleeding is rapid and profuse, or black ('coffee grounds') when less severe. Syncope may occur and is due to hypotension from intravascular volume depletion. Symptoms of anaemia suggest chronic bleeding.
• Lower gastrointestinal bleeding

  This may be due to haemorrhage from the colon, anal canal or small bowel. It is useful to distinguish those patients who present with profuse, acute bleeding from those who present with chronic or subacute bleeding of lesser severity
• Gastro-oesophageal reflux disease (GERD)

  Gastro-oesophageal reflux disease develops when the oesophageal mucosa is exposed to gastroduodenal contents for prolonged periods of time, resulting in symptoms and, in a proportion of cases, oesophagitis.
• Major symptoms of GERD

  • Heartburn
  • Regurgitation, often provoked by bending, straining or lying down
• Other less common symptoms of GERD

  • 'Waterbrash', which is salivation due to reflex salivary gland stimulation as acid enters the gullet
  • Odynophagia (painful swallowing) or dysphagia
  • Atypical chest pain due to oesophageal spasm
  • Hoarseness ('acid laryngitis'), chronic cough, asthma, chest infections
  • Dental erosion in chronic GERD due to acid
• Factors involved in the development of gastro-oesophageal reflux disease

  • Defective oesophageal clearance
  • Abnormal lower oesophageal sphincter: Reduced tone, Inappropriate relaxation
  • Obesity
  • Dietary factors
  • Hiatus hernia
  • Delayed gastric emptying
  • Increased intra-abdominal pressure
• Management of GERD

  • Lifestyle advice
  • Proton Pump Inhibitors (PPIs)/ H2 receptor antagonists/ antacids etc.
  • Laparoscopic anti-reflux surgery
• Dysphagia

  Difficulty in swallowing
• Odynophagia

  Painful swallowing, usually from gastro-oesophageal reflux or candidiasis
• Globus sensation

  Anxious people feel a lump in the throat without organic cause
• Diagnostic and therapeutic approaches for dysphagia

  • Careful history and physical examination may provide clues to the diagnosis
  • Endoscopy is the investigation of choice because it allows biopsy and dilatation of strictures
  • If no abnormality is found, then barium swallow with videofluoroscopic swallowing assessment is indicated to detect major motility disorders
  • In some cases, oesophageal manometry is required. High-resolution manometry allows accurate classification of abnormalities
  • Treatment depends on the underlying cause
• Achalasia of the oesophagus is characterizsed by Characterised by

  a hypertonic lower oesophageal sphincter, which fails to relax in response to the swallowing wave, and failure of propagated oesophageal contraction, leading to progressive dilatation of the gullet.
• Pathogenesis of achalasia

  The cause is unknown. Defective release of nitric oxide by inhibitory neurons in the lower oesophageal sphincter has been reported, and there is degeneration of ganglion cells within the sphincter and the body of the oesophagus. Loss of the dorsal vagal nuclei within the brainstem can be demonstrated in later stages. Infection with Trypanosoma cruzi in Chagas' disease causes a syndrome that is clinically indistinguishable from achalasia.
• Clinical features of achalasia

  The presentation is with dysphagia. This develops slowly, is initially intermittent, and is worse for solids and eased by drinking liquids, and by standing and moving around after eating. Some patients experience episodes of chest pain due to oesophageal spasm. Heartburn does not occur because the closed oesophageal sphincter prevents gastro-oesophageal reflux. Achalasia predisposes to squamous carcinoma of the oesophagus.
• Medication-Induced Esophageal Injury

  Factors related to injury: Sustained-release preparations, Large pills or those with sticky surfaces, Patient's position at the time of ingestion of the drug, and Volume of fluid ingested with the drug.
• Achalasia of the oesophagus

  A condition where the oesophageal sphincter fails to relax during swallowing, making it difficult to swallow
• Achalasia

  • Presentation is with dysphagia (difficulty swallowing)
  • Dysphagia develops slowly, is initially intermittent, and is worse for solids and eased by drinking liquids, and by standing and moving around after eating
  • Some patients experience episodes of chest pain due to oesophageal spasm
  • Heartburn does not occur because the closed oesophageal sphincter prevents gastro-oesophageal reflux
  • Achalasia predisposes to squamous carcinoma of the oesophagus
• Dysphagia

  Difficulty swallowing
• Medication-Induced Esophageal Injury

  • Factors related to injury: Sustained-release preparations, Large pills or those with sticky surfaces, Patient's position at the time of ingestion of the drug, Volume of fluid ingested with the drug
• Potassium supplements and NSAIDs may cause oesophageal ulcers when the tablets are trapped above an oesophageal stricture. Liquid preparations of these drugs should be used in such patients. Bisphosphonates cause oesophageal ulceration and should be used with caution in patients with known oesophageal disorders.
• Abdominal pain


  There are four types: Visceral, Parietal, Referred, and Psychogenic
• Causes of acute abdominal pain

  • Inflammation: Appendicitis, Diverticulitis, Cholecystitis, Pelvic inflammatory disease
  • Perforation/rupture: Peptic ulcer, Diverticular disease
  • Obstruction: Intestinal obstruction, Biliary colic
  • Other (rare): Pancreatitis, Pyelonephritis, Intra-abdominal abscess, Ovarian cyst, Aortic aneurysm, Ureteric colic
• Gastritis


  Two types: Acute and Chronic
• Acute gastritis


  • Erosions and haemorrhagic gastric mucosa on endoscopy; aspirin or NSAID ingestion- most common cause
  • Erosions: breach in the continuity of the mucosa and do not penetrate the muscularis mucosae
  • Asymptomatic / dyspepsia, anorexia, nausea or vomiting, and haematemesis or melaena
  • Treatment: identify the underlying cause, short-term symptomatic therapy with antacids, and acid suppression using PPIs, prokinetics (domperidone) or antiemetics (metoclopramide) may be necessary
• Common causes of acute gastritis

  • Aspirin, NSAIDS
  • H. pylori (initial infection)
  • Alcohol
  • Other drugs, e.g. iron preparations
  • Severe physiological stress, e.g. burns, multi-organ failure, CNS trauma
  • Bile reflux, e.g. following gastric surgery
  • Viral infections, e.g. CMV, herpes simplex virus in HIV-AIDS
• Common causes of chronic non-specific gastritis

  • H. pylori infection
  • Autoimmune (pernicious anaemia)
  • Post-gastrectomy
• Chronic peptic ulcer disease

  A circumscribed ulceration of the gastrointestinal mucosa occurring in areas exposed to acid and pepsin and most often caused by Helicobacter pylori infection
• Locations of peptic ulcers

  • Stomach or duodenum, lower oesophagus, other sites (rare)
• Chronic gastric ulcer


  Usually single; most common site- gastric antrum/junction between antrum and body of the stomach