--- module: 047-02 language: en chapter: 47 title: "Oesophageal, Gastric, Intestinal, and Anorectal Disease" module_title: "Gastrointestinal localisation, mucosal injury, obstruction, bleeding, and inflammatory control" source_sha256: 48ab4f6464ce31b82dbcac3ceee2275c3640a4b1a0da78d5f8d4a1f23944cf21 --- # Localisation, injury, obstruction, bleeding, inflammation ## Localising along the lumen ### Follow the path of luminal contents ### Swallow initiation: mouth, pharynx, cranial nerves ### Retrosternal sticking: oesophageal transit ### Vomiting: proximal propulsion failure or central ### Distension and obstipation: distal obstruction ### Same symptom arises at several levels #### Combine anatomy, timing, content, consequence ## Oropharyngeal dysphagia ### Aspiration can be silent #### Wet voice, cough with meals, recurrent pneumonia ### Videofluoroscopy or endoscopy tests strategies ### Texture change reduces aspiration and hydration #### Review rather than indefinite prescription ### Test strategies with real food #### No cough does not prove safety ### Tube feeding does not prevent all aspiration ### Mouth care reduces aspirated bacterial load ## Oesophageal dysphagia and reflux ### Solids-first progression: narrowing lumen #### Cancer, stricture, ring, eosinophilic inflammation ### Solids and liquids from onset: dysmotility ### Achalasia retains food above a non-relaxing sphincter #### Nocturnal regurgitation and aspiration ### Symptoms may not match acid exposure ### Proton-pump inhibitors work best before meals ### Warning features shift to endoscopic diagnosis ## Gastric mucosal injury ### Mucus-bicarbonate layer, epithelium, blood flow ### Non-steroidal drugs injure systemically and topically ### Helicobacter inflames the mucus niche #### Combination markedly raises ulcer risk ### Dyspepsia alone cannot identify an ulcer ### Suppressing drugs cause false-negative tests ## Upper gastrointestinal haemorrhage ### Circulation and airway before diagnosis ### Initial haemoglobin may be normal #### Whole blood lost before equilibration ### Transfusion individualised, not one threshold #### Excess raises portal pressure #### Too little harms heart and brain ### Risk scores do not override ongoing bleeding ### Rebleeding: repeat endoscopy, embolisation, surgery ### Anticoagulant restart is an active decision ### Varices: vasoactive therapy and antibiotics first ## Diarrhoea and rehydration ### Osmotic diarrhoea falls with fasting ### Secretory diarrhoea continues despite fasting ### Oral rehydration relies on sodium-glucose transport #### Water alone misses sodium loss #### Concentrated sweet drinks worsen osmotic loss ### Antibiotics can harm in toxin syndromes ### Separate deficit from continuing losses ### Avoid antimotility drugs with blood or fever ## Clostridioides difficile and coeliac disease ### Loss of colonisation resistance, toxin colitis ### Test only unformed stool in compatible syndrome ### Nucleic-acid test does not prove toxin injury ### Fulminant disease needs early surgical review ### Coeliac: iron deficiency may be the only sign ### Test serology while gluten is in the diet #### Early exclusion heals mucosa, hides diagnosis ## Inflammatory bowel disease ### Calprotectin shows inflammation, not its cause ### Symptoms may persist after mucosal healing ### Acute severe colitis is a systemic emergency #### Admit, steroid, thromboprophylaxis, surgeon #### Judge response within days #### Rescue therapy or colectomy on failure ### Opioids and anticholinergics worsen dilatation ### Surgical consultation not delayed ## Obstruction and mesenteric ischaemia ### Upstream fluid and gas accumulate #### Vomiting, third-space loss, aspiration risk ### Colicky pain as peristalsis meets the block ### Continuous pain and acidosis suggest strangulation ### Decompression does not remove the lesion ### Analgesia is not withheld ### Non-operative care only without ischaemia signs ### Ischaemia: pain exceeds examination #### Atrial fibrillation, atherosclerosis, low flow #### Normal lactate must not reassure ## Constipation, anorectal bleeding, the final record ### Constipation is more than stool frequency ### Overflow diarrhoea around impaction ### Anorectal bleeding needs visual examination ### Separate symptom control from threatened bowel ### Record level, mechanism, volume, risk ### Symptom relief is not recovery if decline persists