Gastrointestinal (GI) diseases are a source
of substantial morbidity, mortality, and cost.
Diagnosis and management of GI disorders
has been recognized as very important, and
it has been suggested that they have all the
available resources in order to ensure high
standard of care for their patients.
Gastroesophageal reflux disease (GERD) is a
consequence of the failure of the normal anti-
reflux barrier to protect against frequent and
abnormal amounts of gastroesophageal
Common in western countries due to obesity.
(BMI ≥ 30) (M:F= 1:1)
Ref: Sleisenger & Fordtran's Gastrointestinal and Liver Disease 9th
5. Community based study- a defined
area of Dhaka city.
Door to door survey among 1600
adults aged 18 years and above.
Total population included 1417.
Prevalence was 18%.
Ref: Shahed .MD Thesis. BSMMU 2005.
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.
Occasional episodes of gastro-oesophageal
reflux are common in healthy individuals.
GERD affects 30% of the general population.
Ref- Davidsons Principles and Practice of Medicine 23rd Edition, Page:
7. Classic Reflux symptoms:
Heartburn: Occurring after meals, aggravated by
rich food, lying down, nocturnal heartburn
Regurgitation of acidic fluids.
Ref: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 9th Edition,
Page- 713 & 714
►If you smoke - stop.
►Do not drink alcohol.
►Lose weight if needed.
►Eat small meals.
►Wear loose-fitting clothes.
►Avoid lying down for 2-3 hours after a meal.
►Raise the head of your bed 6 to 8 inches by putting blocks of wood
under the bedposts-just using extra pillows will not help.
17. Proton pump inhibitors are the drugs of choice.
PPIs reduce gastric acid secretion up to 90%.
PPIs inhibit meal-stimulated and nocturnal
acid secretion to a significantly greater degree
Controlled studies and a large meta analysis
report showing complete healing of even severe
ulcerative esophagitis after eight weeks in
more than 80% of patients taking PPIs
compared with 51% on H2RAs.
Ref: Sleisenger & Fordtran's Gastrointestinal and Liver Disease 9th Edition,
Page- 723 & Kumar & Clark's Clinical Medicine, 7th Edition Page: 252
19. The term ‘Peptic ulcer’ refers
to an ulcer in the lower
oesophagus, stomach or
duodenum, in the jejunum
after surgical anastomosis to
the stomach or, rarely, in the
ileum adjacent to a Meckel’s
Ref- Davidsons Principles and Practice of Medicine 23rd Edition,
Annual Incidence of Peptic Ulcer 0.1-0.3%.
In Western countries
0.12- 1.5 percent (population based)
1- 6 percent (H pylori positive subjects)
Point prevalence: Around 15% (1985 data)
22. Sites of peptic
Other sites are
Lower end of Oesophagus.
Ulcer at Meckels Diverticulum.
23. Prevalence OF
H. pylori &
Now H pylori is reduced to 50 to 75% people in USA and
BUT remains high in Asia.
In BANGLADESH 90% adults and 84% children are H. Pylori
Only 10 to 15 percent of patients with H. pylori infection
develop ulcer disease.
H. pylori was absent in almost 30 percent of patients with
an endoscopically documented duodenal ulcer.
24. Duodenal ulcer:
Most common form of
Usually located in the
Multiple ulcers or ulcers
distal to the second
portion of duodenum
raise possibility of
Less common than
duodenal ulcer in absence
of non steroidal anti-
Commonly located along
lesser curvature of the
Ref- Davidsons Principles and Practice of Medicine 23rd Edition,
Upper abdominal pain
Feeling fullness after food
Belching, or feeling bloated after eating
Heartburn or acid reflux
Vomiting (may be blood: Hematemesis)
Black- tarry stools (Melaena)
To diagnose peptic ulcer disease
Upper GI Endoscopy
Imaging (Now rarely practiced)
• To establish the etiology-
• Test for Helicobacter pylori
• Assessment of NSAID use
• Additional assessment
General measures: Cigarette smoking, aspirin and
NSAIDs should be avoided.
A. Acid-Antisecretory Agents:
Proton pump inhibitors.
B. Agents Enhancing Mucosal Defenses:
Bismuth, misoprostol and antacids.
C. H pylori Eradication Therapy:
Ref- Current Medical Diagnosis and Treatment 2015,
31. Indication of
Extranodal marginal-zone lymphomas of MALT type.
Family history of gastric cancer.
Previous resection for gastric cancer.
H. pylori-positive dyspepsia.
Long-term NSAID or low-dose aspirin users.
Chronic (> 1 yr) PPI users.
Unexplained vitamin B12 deficiency*
Idiopathic thrombocytopenic purpura*
Iron deficiency anaemia*
*If H. pylori-positive on testing.
Ref- Davidsons Principles and Practice of Medicine 23rd Edition,
32. Not indicated
Gastro-oesophageal reflux disease.
Asymptomatic people without gastric
cancer risk factors.
Ref- Davidsons Principles and Practice of Medicine 23rd Edition,
35. Sequential therapy: Duration 5+5 days
Drugs in Initial 5 days Drugs in subsequent 5 days In drug resistance
PPI (twice daily)
(1 g twice daily)
PPI (twice daily) + clarithromycin (500 mg twice daily)
+ tinidazole / Metronidazole
(500 mg twice daily)
With penicillin allergy or
Levofloxacin (250 mg twice
daily) may be used
Indications for surgery in peptic ulcer:
• Gastric outflow obstruction.
• Persistent ulceration despite adequate medical
• Recurrent ulcer following gastric surgery.
Ref- Davidsons Principles and Practice of Medicine
23rd Edition, Page: 800
Dyspepsia affects 20-40% of adults annually.
7-40% prevalence based on population studies.
50% self medicate.
10-25% will seek medical attention.
Quality of life impaired; more absent work
41. C. Functional Dyspepsia:
Most common cause of chronic dyspepsia.
Three-fourths of patients have no obvious organic
Symptoms may arise from a complex interaction of :
Gastric delayed emptying.
Impaired accommodation to food.
42. Rome III
At least 3 months, with onset at least 6 months
previously, of 1 or more of the following:
Bothersome postprandial fullness.
No evidence of structural disease (including at
upper endoscopy) that is likely to explain the
1. General Measures:
Most patients have mild, intermittent
symptoms that respond to reassurance and
lifestyle changes. Alcohol and caffeine should
be reduced or discontinued.
Patients with postprandial symptoms should
be instructed to consume small, low-fat meals.
A food diary, in which patients record their
food intake, symptoms, and daily events, may
reveal dietary or psychosocial precipitants of
46. 2. Pharmacologic Agents:
Acid suppression therapy for 4-8 weeks with
oral proton pump inhibitors (Esomeprazole,
Rabeprazole, Pantoprazole, dexlansoprazole,
lansoprazole) or H2 blockers (Cimetidine,
Motility agents like Domperidone,
47. 3. H. pylori eradication therapy
Meta-analyses have suggested that a
small number of patients with
functional dyspepsia (less than 10%)
derive benefit from H. Pylori
eradication therapy. Therefore,
patients with functional dyspepsia
should be tested and treated for H
pylori as recommended above.
• Irritable Bowel Syndrome is not a disease. It's a
functional disorder, which means that the
bowel simply does not work as it should.
• (IBS) is a common disorder that affects the
large intestine (colon).
• (IBS) commonly causes cramping,
abdominal pain, bloating, gas, diarrhea
49. What does the
colon do in
The contraction of the colon muscles and the
movement of its contents is controlled by nerves,
hormones, and impulses in the colon muscles.
These contractions move the contents inside the
colon toward the rectum.
During this passage, water and nutrients are
absorbed into the body, and what is left over is
A few times each day contractions push the stool
down the colon, resulting in a bowel Movement.
However, if the muscles of the colon do not contract in
the right way, the contents inside the colon do not
Resulting in abdominal pain, cramps,-
constipation, a sense of incomplete stool
movement, or diarrhea.
What does the
colon do in
52. Causes of IBS
1. Abnormal gastrointestinal (GI) tract movements.
2. A change in the nervous system communication
between the GI and brain.
3. Sensory and motor disorders of the colon.
4. Dietary allergies or food sensitivities.
5. Neurotransmitter imbalance“(decreased
IBS pathophysiology is not clear. Many theories have been
put forward , but the exact cause of IBS is still uncertain.
1. Alteration in GI motility : alteration in frequency and
irregularity of luminal contractions.
2. Visceral hypersensitivity : increased sensation in
response to stimuli.
3. Brain gut axis : alteration in communications
between enteric nervous system and CNS.
4. Post infectious :about 10% of IBS cases are triggered
by an acute gastroenteritis infection.
54. Symptoms of
Pain, distension or abdominal discomfort and
Abnormal bowel habits with periods of
constipation and/or diarrhea.
Sensation of incomplete bowel movement.
Mucus in the stool.
55. Types of
IBS can be subdivided into:
Constipation-predominant : The person tends to
alternate constipation with normal stools.
Symptoms of abdominal cramping or aching are
commonly triggered by eating.
Diarrhea-predominant : The person tends to
experience diarrhea first thing in the morning or
after eating. The need to go to the toilet is
typically urgent and cannot be delayed.
The most important are abdominal pain and
discomfort lasting at least 12 weeks, though the
weeks don't have to occur consecutively
You also need to have at least two of the following:
58. A change in the frequency or consistency of stool.
For example patient may change from having one- normal
formed stool every day to three or more loose stools daily, or
may have only one hard stool every three to four days.
Straining, urgency or a feeling that patient can't empty bowels
Mucus in stool.
Bloating or abdominal distension.
The goals of treatment are symptom
relief and improved quality of life.
Treating IBS can be challenging because
symptoms often are recurrent and
resistant to therapy.
Positive patient-physician interaction is
associated with fewer return visits for
Avoid food that trigger symptoms (such as gases
forming foods as lentils , legumes , and beans )
Low FODMAP diet ( Fermentable Oligo Di Mono-
saccharides And Polyols) : are short chain carbohydrates
that are poorly absorbed in small intestine.
Fiber supplementation : May improve symptoms of
Inflammatory Bowel Disease (IBD) consist of
Ucerative colitis and Crohn’s disease.
Protracted relapsing and remitting course
persisting several years.
They have many similarities and sometimes
difficult to differentiate.
Ulcerative colitis only involves the colon while
Crohn’s disease can involve any part of the
Environmental and genetic components
In both, the intestinal wall is infiltrated with
acute and chronic inflammatory cells
Important differences between them in the
Rectal bleeding with passage of mucus and bloody
diarrhoea accompanied by tenesmus
First attack is usually severe than relapses and
Provokating facors for a relapse
antibiotics or NSAID therapy may all.
72. Some pass small volume fluid stools
others pass pellety stools due to constipation.
In severe cases
weight loss and abdominal pain occur
the patient is toxic, with fever, tachycardia and signs of
The major symptoms are
Diarrhoea usually watery and does not contain blood or
Weight loss because they avoid food due to pain and
Subacute or even acute intestinal obstruction (Ileal Crohn’s)
Some patients present with features of fat, protein or
74. May present as an identical manner to ulcerative
Rectal sparing and the presence of perianal
disease favour a diagnosis of Crohn’s disease.
Symptoms may be of both small bowel and colon
A few patients present with
isolated perianal disease
vomiting from jejunal strictures or
severe oral ulceration
75. Physical examination often reveals
anaemia with glossitis and angular stomatitis.
There is abdominal tenderness, most
(over the inflamed area)
Abdominal mass may be palpable due to-matted
thick loops or intra-abdominal abscess
Perianal skin tags, fissures or fistulae are found in
at least 50% of patients
Life-threatening colonic inflammation
In both ulcerative colitis and Crohn’s colitis
In most extreme cases
colon dilates (toxic megacolon)
bacterial toxins pass freely across the diseased
mucosa into the portal and then systemic
This arises most commonly during the first
attack of colitis
Abdominal X-ray showing
transverse colon is dilated
more than 6 cm.
There is a high risk of colonic
Can occur in the absence of
These are specific to Crohn’s disease
Enteroenteric fistulae can cause diarrhoea
and malabsorption due to blind loop
Enterovesical fistulation causes recurrent
urinary infections and pneumaturia.
An enterovaginal fistula causes a faeculent
Fistulation from the bowel may also cause
perianal or ischiorectal abscesses,
fissures and fistulae.
Cancer (More in Ulcerative Colitis)
Risk increases with the duration and extent of
uncontrolled colonic inflammation
Oral mesalazine and other treatment modalities
reduces the risk of dysplasia and neoplasia in
Full blood count : Anaemia resulting from bleeding
or malabsorption of iron, folic acid or vitamin B12.
Serum albumin: Decrease level -as a consequence
of protein-losing enteropathy, inflammatory
disease or poor nutrition.
The ESR and CRP: Increase level in exacerbations
and in response to abscess formation.
At initial presentation
stool microscopy and culture
examination for Clostridium difficile
ova and cysts of parasite
blood cultures and serological tests
During acute flares
Three separate stool samples should
be sent to maximise sensitivity
Ileocolonoscopy of patients with
Diarrhoea plus raised inflammatory
Alarm features: weight loss, rectal
bleeding and anaemia
In ulcerative colitis, there is
Loss of vascular pattern
Granularity, friability and contact bleeding
with or without ulceration
Colonoscopy In Crohn’s disease
discrete, deep ulcers
strictures and perianal disease (fissures, fistulae and
often with rectal sparing.
Wireless capsule endoscopy useful for small
bowel inflammation (avoid in presence of
Enteroscopy (Double/Single Bolloon or Push)
are used to make a histological diagnosis
Barium enema is a less sensitive investigation than
colonoscopy in patients with colitis .
CT colonogram (where colonoscopy is incomplete)
Barium follow-through demonstrates affected areas of
the bowel as narrowed and ulcerated, often with multiple
MRI enterography (replaced Barium Enenma): can detect
extraintestinal manifestations and assess pelvic and
Plain abdominal X-ray is essential in severe
Small bowel Crohn’s disease
evidence of intestinal obstruction or
displacement of bowel loops by a mass
Ultrasound: very powerful tool to detect
small bowel inflammation and stricture formation
it is rather operator-dependent
CT is limited to screening for complications:
perforation or abscess formation
Both ulcerative colitis and Crohn’s disease are
life-long conditions and have important
Patient support groups have key roles in education,
reassurance and coping.
The key aims of medical therapy are to:
Treat acute attacks (induce remission)
Prevent relapses (maintain remission)
Prevent bowel damage
Detect dysplasia and prevent carcinoma
Select appropriate patients for surgery.
For Ulcerative Colitis
mesalazine suppository 1 g ( for Proctitis)
oral 5-aminosalicylate (5-ASA) therapy
Topical corticosteroids are less effective
In resistant disease systemic corticosteroids or
Active left-sided or extensive ulcerative colitis.
In mild to moderately active cases, the combination of a
once daily oral and a topical 5-ASA preparation (‘top and
tail approach’) is usually effective.
In patients who do not respond to this approach within
2–4 weeks, oral prednisolone (40 mg daily, tapered by 5
mg/week over an 8-week total course) is indicated.
Corticosteroids should never be used for maintenance
therapy. At the first signs of corticosteroid resistance
(lack of efficacy) or in patients who require high
corticosteroid doses to maintain control,
immunosuppressive therapy with a thiopurine should
Severe ulcerative colitis.
Patients who fail to respond to maximal oral
therapy and those who present with acute
Topical and oral aminosalicylates have no role
Response to therapy is judged over the first 3
Considered for medical rescue therapy with
ciclosporin (intravenous infusion or oral) or
infliximab (5 mg/kg), which, in approximately 60%
of cases, can avoid the need for urgent colectomy.
Urgent colectomy is required:
Patients who develop colonic dilatation (> 6 cm),
those whose clinical and laboratory measurements
those who do not respond after 7–10 days maximal
Subtotal colectomy can also be performed
laparoscopically, given sufficient local
Maintenance of remission.
Life-long maintenance therapy is
recommended for all patients with left-sided or
extensive disease but is not necessary in those
Once-daily oral 5-aminosalicylates are the preferred
Patients who frequently relapse despite
aminosalicylate drugs should be treated with
Principles of treatment.
Crohn’s disease is a progressive condition may
result in stricture or fistula formation if
It is therefore important to agree long-term
treatment goals with the patient;
To induce remission and then maintain corticosteroid-
free remission with a normal quality of life.
Treatment should focus on monitoring the patient
carefully for evidence of disease activity and
Ensuring that mucosal healing is achieved.
100. Induction of remission.
Corticosteroids remain the mainstay of treatment.
Drug of first choice is budesonide, (90% first-
pass metabolism & very little systemic toxicity).
9 mg once daily for 6 weeks, with a gradual reduction
If no response within 2 weeks,
prednisolone, 40 mg daily, reducing by 5 mg/week over
Calcium and vitamin D supplements
101. As an alternative to corticosteroid therapy,
enteral nutrition with either an elemental
(constituent amino acids) or polymeric (liquid
protein) diet may induce remission.
It is particularly effective in children, in whom
equal efficacy to corticosteroids has been
demonstrated, and in extensive ileal disease in
adults. As well as resting the gut and providing
excellent nutritional support, it also has a
direct anti-inflammatory effect.
102. Some patients with severe colonic disease
require admission to hospital for intravenous
In severe ileal or panenteric disease, induction
therapy with an anti-TNF agent is appropriate,
provided that acute perforating complications,
such as abscess, have not occurred.
103. Maintenance therapy.
thiopurines (azathioprine and
methotrexate: orally and once weeklyis also.
Combination therapy with an
immunosuppressant and an anti-TNF antibody
is the most effective strategy but costs are high
and there is an increased risk of serious
104. Careful monitoring of disease is the key to
maintaining sustained remission and
preventing the accumulation of bowel damage
in Crohn’s disease.
Cigarette smokers should be strongly
counselled to stop smoking at every possible
105. Fistulae and perianal disease.
Fistulae may develop in relation to active Crohn’s
disease and are often associated with sepsis. The first
step is to define the site by imaging (usually MRI of the
Surgical exploration by an examination under
anaesthetic is usually then required, to delineate the
anatomy and drain abscesses.
Seton sutures can be inserted through fistula tracts to
ensure adequate drainage and to prevent future sepsis.
Corticosteroids are ineffective.
106. For simple perianal disease, metronidazole
and/or ciprofloxacin are first-line therapies.
Thiopurines can be used in chronic disease but
do not usually result in fistula healing.
Infliximab and adalimumab can heal fistulae
and perianal disease in many patients and are
indicated when the measures described above
have been ineffective.
Up to 60% of patients with extensive ulcerative colitis
eventually require surgery.
Surgery involves removal of the entire colon and rectum,
and cures the patient. One third of those with pancolitis
undergo colectomy within 5 years of diagnosis.
The choice of procedure is either panproctocolectomy
with ileostomy, or proctocolectomy with ileal–anal
The indications for surgery are similar to those for
Operations are often necessary to deal with fistulae,
abscesses and perianal disease, and may also be
required to relieve small or large bowel obstruction.
In contrast to ulcerative colitis, surgery is not curative
and disease recurrence is the rule.
Antibiotics are effective in the short term only.
Obstructing or fistulating small bowel disease
may require resection of affected tissue.
Patients who have localised segments of
Crohn’s colitis may be managed by segmental
resection and/or multiple stricturoplasties, in
which the stricture is not resected but instead
incised in its longitudinal axis and sutured
Chronic ill health in childhood or adolescent
IBD may result in
metabolic bone disease and
Treatment is similar to that described for adults
and may require corticosteroids,
immunosuppressive drugs, biological agents
A women’s ability to become pregnant is
adversely affected by active IBDDuring
The rule of thirds applies – roughly
one-third of women improve,
one-third get worse and
one third remain stable with active disease.
In the post-partum period, these changes
sometimes reverse spontaneously.
Metabolic bone disease
Patients with IBD are prone to developing
osteoporosis due to effects of chronic
inflammation, corticosteroids, weight loss,
malnutrition and malabsorption.
Osteomalacia can also occur in Crohn’s disease
that is complicated by malabsorption, but is
less common than osteoporosis
Microscopic colitis, which comprises two related
lymphocytic colitis and
Cause is unknown.
The presentation is with watery diarrhoea.
The colonoscopic appearances are normal but
histological examination of biopsies shows a range of
Notas do Editor
In some cases, peptic ulcers heal without treatment, but ulcers that have not been treated tend to recur. Many people with ulcers (sometimes called “peptic ulcer disease”) need treatment to relieve symptoms and prevent complications.
● drinking alcohol does not appear to be a cause of ulcers, alcohol abuse can interfere with ulcer healing.
The prevalence of H. pylori in patients with DU is changing in some parts of the world. While H. pylori infection remains very common in patients from Asia with DU, it is becoming less common in patients from the United States and parts of Europe
Some people with peptic ulcers do not have any symptoms. (Ulcers that cause no symptoms are sometimes called “silent ulcers.”)
the timing of the upper endoscopy may be deferred to 12 weeks after therapy in the absence of alarm features
Other tests: PCR, salivary assays, urinay assays.
Ulcer penetration refers to penetration of the ulcer through the bowel wall without free perforation or leakage of luminal contents into the peritoneal cavity. Penetration occurs in descending order of frequency into the pancreas, lesser omentum, biliary tract, liver, greater omentum, mesocolon, colon, and vascular structures. Antral and duodenal ulcers can penetrate into the pancreas. Pyloric or prepyloric ulcers can penetrate the duodenum, eventually leading to a gastroduodenal fistula evident as a "double" pylorus.
Haemorrhage due to erosion of a major artery is rare but can occur in both conditions.
Faecal calprotectin is high sensitivity for detecting gastrointestinal inflammation and may be elevated, even when the CRP is normal.
It is particularly useful in distinguishing inflammatory bowel disease from irritable bowel syndrome at diagnosis, and
Subsequent monitoring of disease activity.
Biopsies should be taken from each anatomical to confirm the diagnosis and define disease extent, and also to seek dysplasia in patients with long-standing colitis.
All children and most adults with Crohn’s disease should have upper gastrointestinal endoscopy and biopsy to complete their staging.
Small bowel imaging is essential to complete staging of Crohn’s disease.
The oral 5-ASA is continued long-term to prevent relapse and minimise the risk of dysplasia.
. Before surgery, patients must be
counselled by doctors, stoma nurses and patients who
have undergone similar surgery.
The only method that has consistently been shown to reduce post-operative recurrence is smoking cessation. Surgery should be as conservative as possible in order to minimise loss of viable intestine and to avoid creation of a short bowel syndrome.
who have extensive colitis require total colectomy but ileal–anal pouch formation should be avoided because of the high risk of recurrence within the pouch and subsequent fistulae, abscess formation and pouch failure.
Emerging data demonstrate that aggressive medical therapy, coupled with intense monitoring, probably reduces the requirement for surgery substantially.
Loss of schooling and social contact, as well as frequent hospitalisation, can have important psychosocial consequences.
Monitoring of height, weight and sexual development is crucial.
Children with IBD should be manage by specialised paediatric gastroenterologists and transitioned to adult care in dedicated clinics
. Pre-conceptual counselling should focus on optimising disease control.
Drug therapy, including aminosalicylates, corticosteroids and azathioprine, can be safely continued throughout pregnancy but methotrexate must be avoided, both during pregnancy and if the patient is trying to conceive
. The risk of osteoporosis increases with age and with the dose and duration of corticosteroid therapy.
It is therefore recommended that biopsies of the right and left colon plus terminal ileum should beundertaken in all patients undergoing colonoscopy for
Collagenous colitis is characterised by the presence of a submucosal band of collagen, often with a chronic inflammatory infiltrate. The disease is more
common in women and may be associated with rheumatoid arthritis, diabetes, coeliac disease and some drug therapies, such as NSAIDs or PPIs. Treatment with budesonide is usually effective but the condition will recur in some patients on discontinuation of therapy.