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