Gastrointestinal disease

Published on 02/03/2015 by admin

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Last modified 02/03/2015

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5 Gastrointestinal disease

Symptoms

Dyspepsia and indigestion

The term dyspepsia is used to describe a variety of upper abdominal symptoms, including nausea, heartburn, acidity, pain or discomfort, wind, fullness or belching. The term indigestion is used by patients to describe any symptom that is food-related. Indigestion is common and most people will have experienced it at some time.

Treatment

Treatment is with antacid therapy (Table 5.1).

Table 5.1 Antacid therapy

Class of drug Drug Dose
H2-receptor antagonists Cimetidine 400 mg twice daily
Famotidine 40 mg daily
Nizatidine 300 mg daily
Ranitidine 300 mg daily
Proton pump inhibitors Esomeprazole 20 mg daily
Lansoprazole 30 mg daily
Omeprazole 20 mg daily
Pantoprazole 40 mg daily
Rabeprazole 20 mg daily
Antacids Aluminium hydroxide 10–20 mL 3 times daily
Magnesium carbonate 10 mL 3 times daily
Magnesium trisilicate 10–20 mL 3 times daily
Aluminium and magnesium complexes 10 mL between meals and at bedtime
Others Alginates and antacids 2 tablets twice daily
Chelates and complexes, e.g. tripotassium, dicitratobismuthate, sucralfate 2 tablets twice daily

Nausea and vomiting

Many gastrointestinal conditions are associated with vomiting, but nausea and vomiting without abdominal pain are frequently non-gastrointestinal in origin, e.g. acute infections, CNS disease and drug ingestion.

Treatment

Many patients require no therapy. Food is usually withheld and fluids only are allowed. With more persistent vomiting, IV fluids, e.g. 0.9% saline (p. 369), are given for dehydration and correction of electrolyte abnormalities. A naso-gastric tube is inserted if there is bowel obstruction.

Dopamine receptor antagonists

Diarrhoea

Acute diarrhoea

Acute diarrhoea is very common and is usually due to dietary indiscretion, infectious agents, toxins or drugs, e.g. antibiotics, magnesium-containing antacids, or laxatives. It is usually self-limiting and ceases in 24–48 hours with no treatment.

All produce constipation if given frequently.

Chronic diarrhoea

Chronic diarrhoea refers to diarrhoea of more than 4 weeks’ duration. It can be due to a variety of causes (usually non-infective) including inflammation (inflammatory bowel disease), drugs (metformin, statins), functional factors, malabsorption or cancer (change in bowel habit), the treatments for which are described elsewhere.

Constipation

This term is used for the infrequent passage of stool (< 2 per week), straining > 25% of the time or passage of hard stools and incomplete evacuation. Headache, malaise, halitosis, abdominal bloating and discomfort are often attributed to constipation without any factual evidence.

Constipation can come on acutely and, in the older patient, may indicate an organic disorder. Chronic constipation lasting years is usually functional.

Local anal diseases, e.g. fissures or haemorrhoids, are associated with constipation, as are some drugs, e.g. opiates, antimuscarinics, calcium channel blockers (such as verapamil), antidepressants and iron, and systemic disorders, e.g. hypothyroidism, hypercalcaemia and diabetes mellitus.

Rectal examination, flexible sigmoidoscopy/colonoscopy or CT pneumocolon (barium enema is being used less) may be necessary to rule out structural diseases in recent-onset constipation.

Treatment

Laxatives (Box 5.2)

Gastro-oesophageal reflux disease

Reflux is extremely common in the general population, causing mild indigestion and heartburn.

Heartburn is the major feature and is mainly due to direct stimulation of the hypersensitive oesophageal mucosa, but also partly caused by spasm of the distal oesophageal muscle. It is aggravated by bending, stooping or lying down and may be relieved by antacids. The patient may complain of a burning pain on drinking hot liquids or alcohol.

Regurgitation of food and ‘acid’ into the mouth occurs, particularly when the patient is bending or lying flat. Aspiration into the lungs, producing pneumonia, is unusual without an accompanying stricture, but cough and nocturnal asthma from regurgitation and aspiration can occur. The differential diagnosis of the retrosternal pain from angina can be difficult; 20% of cases admitted to a coronary care unit have gastro-oesophageal reflux disease (GORD).

Treatment

Medical treatment (Table 5.1)

Prokinetic agents metoclopramide 10 mg 3 times daily and domperidone 10 mg 3 times daily are dopamine antagonists (for side-effects, see p. 644). They are occasionally helpful, as they enhance peristalsis and speed gastric emptying. Cisapride has been withdrawn because it increases the Q–Tc interval and the risk of arrhythmias.

Complications

Barrett’s oesophagus. This occurs as a result of longstanding reflux (Fig. 5.1). It consists of columnar epithelium with intestinal metaplasia extending upwards into the lower oesophagus and replacing normal squamous epithelium. Barrett’s oesophagus (even short segment < 3 cm) is pre-malignant for adenocarcinoma. Risk factors for progression are male sex, age > 45 years, length of segment > 8 cm, early age of onset and duration of symptoms of GORD, the presence of ulceration and stricture and a family history. Dysplasia is patchy and biopsies from all four quadrants (every 2 cm) of the Barrett’s segment must be performed. There is some evidence that anti-reflux surgery leads to Barrett’s regression. Patients without dysplasia do not require surveillance. Low-grade dysplasia requires regular endoscopic surveillance. High-grade dysplasia is now treated with radiofrequency ablation using the HALO system or local endomucosal resection. Endoscopic ablation therapy with photodynamic therapy or laser is also used.

Other oesophageal disorders

Achalasia

Achalasia is characterized by aperistalsis in the body of the oesophagus and failure of relaxation of the lower oesophageal sphincter (LOS) on initiation of swallowing.

The disease presents at any age with a long history of intermittent dysphagia for both liquids and solids, and regurgitation of food from the dilated oesophagus. Aspiration pneumonia may result. Severe retrosternal chest pain due to vigorous non-peristaltic contraction of the oesophagus occurs, particularly in younger patients.

Treatment

GORD is a common complication, with all successful treatments necessitating PPI therapy in most patients.

Peptic ulcer disease

Peptic ulcers are mainly due to Helicobacter pylori infection or non-steroidal anti-inflammatory drugs (NSAIDs), including aspirin.

Helicobacter pylori

This is a spiral-shaped, Gram-negative, urease-producing bacterium. It is found in the gastric antrum and in areas of gastric metaplasia in the duodenum, in 95% of patients with a duodenal ulcer and 75% of patients with a gastric ulcer. H. pylori is also present in people with no ulcer disease and in up to 80% in people from developing countries. It can be identified by the following methods:

Gastrointestinal haemorrhage

Acute upper gastrointestinal bleeding

Haematemesis is the vomiting of blood from a lesion proximal to the distal duodenum. Melaena is the passage of black tarry stools; the black colour is due to altered blood — 50 mL or more is required to produce this. Melaena can occur with bleeding from any lesion in areas proximal to and including the caecum.

Unaltered or ‘maroon blood’ passed per rectum can be due to an upper gastrointestinal bleed if the bleed is massive.