--- module: 047-01 language: en chapter: 47 title: "Oesophageal, Gastric, Intestinal, and Anorectal Disease" module_title: "Foundations" source_sha256: c3727ac8ccd8adeeb8a66508a25bed3dd95cc0852b4f3d4c71f44ef4e0de2ffa --- # Oesophageal, gastric, intestinal, and anorectal disease ## Orientation ### Localise, then mechanism and tempo ### Recognise bleeding, perforation, ischaemia, cancer early ## Oesophageal disease ### Oropharyngeal: trouble initiating, cough, aspiration ### Oesophageal: food sticks after initiation #### Solids first suggests mechanical narrowing #### Solids and liquids from outset suggests dysmotility ### Reflux crosses an incompetent antireflux barrier #### Sphincter relaxation, hiatus hernia, obesity #### Acid exposure: oesophagitis, stricture, Barrett #### Barrett oesophagus raises adenocarcinoma risk ### Weight loss, positional measures, proton-pump inhibition #### Long-term therapy needs a clear indication #### Warning features require endoscopy ### Achalasia: loss of inhibitory myenteric neurons #### Sphincter fails to relax, peristalsis absent #### Manometry for motor pattern, endoscopy for cancer #### Dilation or myotomy lowers outflow resistance ## Gastritis and peptic ulcer disease ### Defences: mucus, bicarbonate, blood flow, prostaglandins ### Injury when acid, drugs, or infection exceed defences ### Gastritis is histological, dyspepsia is symptomatic ### Helicobacter pylori colonises gastric mucus #### Ulcer, atrophy, adenocarcinoma, lymphoma #### Acid suppression, antibiotics, sometimes bismuth #### Stop suppressing agents before eradication test ### Non-steroidal drugs reduce protective prostaglandins #### Ulceration without warning pain ### Complications: bleeding, perforation, outlet block #### Peritonism: resuscitate, image, urgent surgery ## Gastrointestinal bleeding ### Haematemesis or melaena usually upper ### Haematochezia often lower, or brisk upper ### Airway, perfusion, access, crossmatch, coagulopathy ### Serial measures beat one normal observation ### Endoscopy localises and treats upper lesions #### Proton-pump inhibition supports ulcer haemostasis #### Varices: vasoactive drugs, antibiotics, endoscopy ### Lower: colonoscopy, angiography, or surgery ## Coeliac disease and malabsorption ### Gluten triggers enteropathy in susceptible people #### Villous injury reduces absorptive surface ### Test tissue-transglutaminase IgA while eating gluten #### Total IgA, alternative serology if deficient #### Biopsy confirms, lifelong gluten exclusion ### Malabsorption: enzyme, bile, mucosa, overgrowth ### Albumin also reflects inflammation and dilution ## Diarrhoea and infectious enteritis ### Osmotic, secretory, inflammatory, fatty, motility ### Blood, fever, travel, antibiotics change testing ### Oral rehydration uses sodium-glucose cotransport ### Antibiotics selective: toxin disease, resistance ### Clostridioides difficile after microbiome disruption #### Test only compatible symptomatic patients #### Stop precipitating drugs, isolate, treat enterally ### Chronic: review medicines, diet, endocrine causes #### Nocturnal symptoms, blood, weight loss warn #### Faecal markers detect inflammation, not cause ## Inflammatory bowel disease ### Ulcerative colitis: continuous mucosal, from rectum ### Crohn disease: patchy transmural, mouth to anus #### Strictures, fistulas, abscesses, perianal disease ### Treatment matches location and severity #### Corticosteroids induce, do not maintain #### Check infection and vaccination first ### Acute severe colitis: admit, steroid, plan rescue ### Megacolon, perforation, dysplasia need surgery ## Diverticular and functional bowel disease ### Diverticula: mucosal outpouchings at weak points ### Diverticulitis: left-lower pain, fever, bowel change #### Computed tomography defines complicated disease #### Stable cases may avoid antibiotics ### Irritable bowel: gut-brain interaction disorder #### Positive diagnosis after warning features #### Avoid low-yield tests that reinforce fear ### Constipation: diet, drugs, pelvic floor, transit #### Fibre worsens pain with obstruction or loading ## Obstruction, ischaemia, and anorectal disease ### Colicky pain, vomiting, distension, no flatus #### Small bowel: adhesions and hernias #### Colon: cancer, volvulus, diverticular stricture ### Strangulation compromises blood flow #### Continuous pain, fever, acidosis, peritonism ### Mesenteric ischaemia: pain exceeds examination #### Rapid progression to necrosis #### Lactate may be normal early ### Perianal abscess needs drainage, fistula may follow ### New rectal bleeding is not assumed benign