Disease What is it?

•Acute, chronic, or recurrent pain or discomfort

Dyspepsia centered in the upper abdomen

•Spiral gram-negative rod, resides adjacent to

H. Pylori epithelial cells at the mucosal surface and in
gastric pits

•Nausea - a vague, intensely disagreeable

sensation of sickness or “queasiness” and is
distinguished from anorexia. Vomiting – puking,
Nausea & Vomiting barfing, hurling, spewing, blowing chunks,
Retching - spasmodic respiratory and abdominal
movements

Disease What is it?

•Involuntary contractions of the diaphragm; May

Singultus (Hiccups) only involve one hemidiaphragm
Left > Right
 •Eructation – Belching: The involuntary or
voluntary release of gas from the stomach or
esophagus, after meals, gastric distension resuts
Gastrointestinal Gas in transient lower esophageal sphincter
relaxation, aerophagia; Flatus: farting (swallowed
air, bacterial fermentation)

Constipation

Disease What is it?

Acute, non-inflammatory
Diarrhea
Acute Imflammatory
Diarrhea

Disease What is it?

Chronic Diarrhea
Acute Upper GI Bleeding Bleeding proximal to the Ligament of Treitz

Disease What is it?

Bleeding distal to the Ligament of Treitz, majority

Acute Lower GI Bleeding of lower GI bleed from the colon, typically lower
risk than upper GI

•GI bleeding of unknown origin, GI Bleeding that

persists after intial upper and lower endoscopic
Obscure GI Bleeding evaluation, Obscure-overt vs. Obscure-occult,
commonly in small intestine
How does the patient describe it? Symptoms?

“Upset Stomach”

How does the patient describe it? Symptoms?

 –patients complain of constipation as a decrease in
their typical bowel movement frequency, infrequent
stools, hard stools, excessive straining, a sense of
incomplete evacuation

How does the patient describe it? Symptoms?

–Typically patients complain of diarrhea as an increase

in their typical bowel movement frequency, frequent
stools (up to 10 stools/day), loose, watery stools,
urgency; Abd cramps, bloating, nausea, vomit)
Loose, bloody stools (lower in volume), fever, Severe
LLQ abd cramps, Urgency, Tenesmus

How does the patient describe it? Symptoms?

OSMOTIC: Resolve when fasting; SECRETORY: High

volume, watery stool, little to no change with fasting;
MOTILITY: IBS, pain and altered bowel habits
 "vomiting blood, coffee grounds"(hematemesis),
"dark, tarry stool" (melena, can occur with 50 ml
blood loss), hematochezia (+/- 10%, very rare, only in
severe upper GI bleed. More than 1L), may be
assocaited with epigastric, abd pain

How does the patient describe it? Symptoms?

Hematochezia with or without pain. Bright red blood

(Left colonic source: hemorrhoids, fissure,
diverticulitis, IBD, colitis), Maroon (small intestine or
right colonic source), Black (upper GI); pain with
defacation (external hemorrhoids, anal fissure), Abd
pain/cramps (IBD-small vol bleed, Colitis), Painless
(Internal hemorrhoids-small drips blood, when wiping,
streaks. diverticular bleeding, large volume)

no obvious bleeding or change in stool color (may lose

100 ml/day)
 When is it clinically relevant? How is it defined?

Epigastric Pain or Burning, Early Satiety,

≥ 1 month Postprandial Fullness

When is it clinically relevant? How is it defined?

•Persistent hiccups may be a sign of serious

underlying pathology. CNS neoplasm, infection,
trauma. Metabolic: uremia, hypocapnia. Chronic
irritation of vagus or phrenic nerve. Post-op.
Psychogenic. Warrants full history and physical
exam!
problematic when symptomatic

When is it clinically relevant? How is it defined?

Acute (less than 2 weeks), chronic (longer than

4 weeks); Bloody vs. non- bloody; Persistent
Diarrhea (between 2 & 4 weeks)
 Acute (less than 2 weeks), chronic (longer than
4 weeks); Bloody vs. non- bloody; Persistent
Diarrhea (between 2 & 4 weeks)

When is it clinically relevant? How is it defined?

present for more than 4 weeks; OSMOTIC:

Resolve when fasting, increased stool osmotic
gap; SECRETORY: Increased intenstinal
secretion or decreased absorption, little to no
change with fasting; MOTILITY: IBS, pain and
altered bowel habits
 Unstable: less than 100mmHg SBP (severe),
Pulse over 100bpm (moderate); Stable:
Normal pulse/BP

When is it clinically relevant? How is it defined?

 Etiology/ Causes Patient History

Nonspecific, Acute/Chronic?, location,

Food/Drug Intolerance, Functional Dyspepsia, quality, duration, relationship to meals,
Luminal GI Tract Dysfunction (organic disorders), H. Changes in diet, exercise, stress,
Pylori, Pancreatic, Biliary Tract Disease, Other ETOH/TOB, acidic/spicy foods, Med Hx,
comorbidities Fever, chills, weight loss, n/v/d, etc.

Acute Onset- without abd pain: Food poisoning, Is nausea with or w/o vomit? Onset,
acute gastroenteritis, systemic illness; relation to meals, ABD pain? Location?
with abd pain: peritoneal irritation, acute Meds?, dietary changes? Is anyone else
obstruction, gastroparesis; early morning, around you sick?, any other GI
pregnancy symptoms?

Afferent vagal fibers from viscera (serotonin 5-HT3

receptors, stimulated b distension, irritation, or
infection), stimulation of fibers of the vestibular
system, higher CNS (amygdala) (sights, smells, etc),
chemroreceptor trigger zone (drugs, toxins,
hypoxia, uremia, acidosis, radiation therapy.

Etiology/ Causes Patient History

Benign, self-limiting. Gastric distension (sodas, air

swallowing, overeating), sudden temp changes,
ETOH, heightened emotion
 Flatus: FODMAPS, lactose, fructose, polypols,
fructans

Inadequate fiber, poor hydration, por bowel habits

(holding it in too long), Systemic Disease
(hypothyroidism, diabetes), Cancer, Meds (opoids, History will differentiate between
diurectics, calcium/iron supplements, CCB's), IBS; primary and secondary. Ask if they have
Primary (more common): no structural
abnormailities/disease, may complain if bloating, systemic symptoms, meds, prior Hx
constipation
infrequesnt stools, straining; Secondary: caused by
systemic disease, meds, obstructing leasions
(cancer), more sudden in onset, no prior Hx

Etiology/ Causes Patient History

Viral ( Norovirus, Rotavirus), Protozoal (Giarda Bloody/non-bloody? Recent travel? Diet

changes? New foods? Recent Abx use/
lamblia (water park) Anyone sick at home?
 Bloody/non-bloody? Recent travel? Diet
E. Coli, Shigella, Salmonella, C. difficile (recent ABx) changes? New foods? Recent Abx use/
Anyone sick at home?

Etiology/ Causes Patient History

CARB MALABSORPTION: Do you eat

Meds (most common), osmotic diarrhea, dairy? How much? Artificial
secretory/inflammatory/malabsorptive/motility/ Sweeteners? ALL CHRONIC DIARRHEA:
systemic disorders, chronic infections; OSMOTIC: Continuous or intermittent?
carbohydrate malabsorption, laxative abuse, Relationship to meals? Occurs at night?
malabsorption syndromes; SECRETORY: Endocrine Occurs during fasting? Is your stool
tumors, Bile salt malabsorption; CHRONIC bulky, greasy? Smell bad? Blood or pus?
INFECTION: parasites (Giardia, E.Histolytica, Abd pain? What meds are you taking?
Cyclospora)/intestinal nematodes Supplements/vitamins? Any weight
loss? Stressors?
 PUD (40%); Portal HTN (10-20%) (esophageal
Varives=high mortality rate); Mallory-Weiss (from
forceful vomit/retching (ETOH abuse); Vascular
anomalies (7%) (Angioectasis, Telangiectasis);
Gastric Neoplasm (1%); Erosive Gastritis,
(NSAID/ETOH), Erosive Esophagitis (chronic GERD);
Booerhave Syndrome (tear from forceful retching,
ETOH abuse)

Etiology/ Causes Patient History

COMMON IN UNDER 50 YRS: Anorectal Disease

(hemorrhoids, fissures, ulcers), IBD (ulcerative
colitis, Crohn Disease), Infectious colitis; COMMON
IN OVER 50YRS: neoplasm, Angioectasis (more
common over 70yrs), ischemic colitis, diverticulosis
(painless, bright red blood, large volume)
 RED FLAGS Physical Exam

Typically Unremarkable, may elicit mil-epigastric

TTP, Presence of organomegaly, abdominal
Unintended weight loss, dysphagia,
recurrent vomiting, GI Bleeding, Anemia mass, or focal, severe TTP is suggestive of
another diagnosis

Dehydration (Dry, mucous membranes, skin

turgor, POS TILTS); ABD exam: TTP? Distension?
Organomegaly?

RED FLAGS Physical Exam

 investigate for potential malabsorption
syndromes

hematochezia, weight loss, positive FOBT,

family history of colon cancer or Dullness to percussion in the left quadrants. DRE
(rules out structural abnormalities and may
inflammatory bowel disease encounter hard stool)

RED FLAGS Physical Exam

Dizziness, light headedness, orthostatic

hypotension
RED FLAGS Physical Exam
 STABLE VS UNSTABLE!

RED FLAGS Physical Exam

ASSESS FOR STABILITY FIRST!

 Labs Procedures

EGD; if S/Sx suggest another Dx or failure to

CBC, Chem 17 (CMP), TSH, H. Pylori, Celiac respond to therapy w/I 6 weeks,**All patients
Disease, stool for ova/parasites, fecal fat ≥ 60 y/o w/ new onset
**All patients with alarm signs

Fecal Antigen Test, Carbon-13 urea breath

test, H. Pylori serology

Imaging: not indicated unless Hx/physical

not always necessary, but CBC, BMP/CMP
may be necessary exam suggests a focal cause; Plain Films (abd
plat/upright) or CT

Labs Procedures
 CBC, Serum electrolytes (CMP) - Calcium, Abdominal x-ray shows non-specific bowel gas
pattern, endoscopy (Colonoscopy or flexible
glucose, Thyroid panel sigmoidoscopy)

Labs Procedures

Labs usually not needed, unless persistent

for longer than 7 days or if there is
constant, severe stools/dehydration; fecal
leukocytes (should be negative); Testing as
clinically indicated for Clostridium difficile
toxin (C.diff assay), and ova and parasites
(three samples); fecal lactoferrin
Routine stool bacterial cultures (including E
coli O157:H7); Testing as clinically
indicated for Clostridium difficile toxin
(C.diff assay), and ova and parasites (three
samples); fecal leukocytes, fecal lactoferrin

Labs Procedures

ALL CHRONIC DIARRHEA: CBC, Chem 17,

LFT, Thyroid studies, ESR, CRP; STOOL:
Colonoscopy (To exclude IBD and neoplasm);
Culture, Leukocytes, Lactoferrin, Occult 24 Hr stool (total weight/total fat)
blood, O&P, electrolytes
 Endoscopy; fluid/blood replacement (2-4
CBC, PT/INR, CMP, type and screen PRBC); UNSTABLE: start isotonic IV, NG Tube;
EGD (in ALL upper GI bleeds, within 24hrs)

Labs Procedures

First exclude Upper GI source, anoscopy,

signmoidoscopy, colonoscopy
(vasoconstrictive injection, cautery,
CBC, CMP (Anemia = ominous sign, clips/bands), technetium scan, angiography,
neoplasm) capsule endoscopy, inttra-arterial
embolization, surgery (last resort, indicated if
the patint requires over 6 units of PRBC in 24
hrs or more than 10 units total

Fecal Occult Blood Test, Fecal

Immunochemical Test (lower GI only),
Presence of unexplained anemia on CBC
(neoplasm), colonsocopy (-+FOBT without
anemia), upper endoscopy AND
colonsocopy(-+ FOBT with anemia)
 Treatment Treatment -Meds

Patients youngr than 60yrs, no red flags,

H. Pylori testing, Lifestyle Changes
( ETOH/Caffeine, smaller meals), food PPI x 4 wks
diary, meds, psychotherapy

Triple Therapy; PPI,Clarithromycin,

Amoxicillin (metronidazole, if PCN
allergic); Quadruple Therapy: PPI,
Bismuth Subsalicylate, Tetracycline,
Metronidazole

Antiemetics: Ondansetron; Dopamine

supportive (fluids, BRAT diet, ginger) Antagonists:Promethazine,
profile, quarters. IV if pt cannot tolerate Procloperazine; Antihistmines: Meclizine,
fluids Dimenhydrinate, Scopolamine
Transdermal, Diphenhydramine

Treatment Treatment -Meds

Teaspoon of dry sugar, stimluation of the

nasopharynx, valsalva, rebreathing, Chlorpromazine
scaring, relief of gastric distension (if any)
 Beano (alpha-d-galactosidase enzyme),
Avoid FODMAP foods
simethicone (Gas-X)

Fiber, Laxatives (Magnesium hydroxide

(Milk of Magnesia, Epsom Salts)
Polyethelyne glycol 3350 (Miralax)
Dietary/Lifestyle changes, Timing, **Polyethelyne glycol (GoLYTELY)
positioning, Increase fiber/ water intake, **Magnesium citrate, Stimulant Laxatives
medication changes, exercise (Bisacodyl (Dulcolax)
Senna (ExLax), stool surfactants
(Docusate sodium), Enema (Tap water,
Saline)

Treatment Treatment -Meds

oral salts if necessary, Antidiarrheals

(loperamide, bismuth subsalicylate) ANTI
DIARRHEALS/ABx NOT ALWAYS
BRAT diet, avoid high-fiber, fat, dairy, INDICATED;use as necessary to allow
caffeine, Rehydrate people to be able to work; Abx, if
necessary Ciprofloxacin, Ofloxacin,
levofloxacin, trimethoprim-sulfa,
doxycycline)
 oral salts if necessary, Antidiarrheals
(loperamide, bismuth subsalicylate) ANTI
DIARRHEALS/ABx NOT ALWAYS
INDICATED;use as necessary to allow
people to be able to work; Abx, if
BRAT diet, avoid high-fiber, fat, dairy, necessary Ciprofloxacin, Ofloxacin,
caffeine, Rehydrate; IV if INPATIENT
levofloxacin, trimethoprim-sulfa,
doxycycline); TRAVELER'S DIARRHEA:
fluoroquinolones (DOC), Azithromycin or
Rifaximin if patient cannot tolerate
fluoroquinolones or going to SE Asia

Treatment Treatment -Meds

First, rule out most common etiologies Review all meds and discontinue/change
(Meds, IBS, Lactose intolerance),
Evaluation directed at most likely etiology if necessary; treatment will be dependent
on etiology
based on symptoms and history
 Assessment/ Stabilization of IV/PO PPI (lowers risk for re-bleed for
hemodynamic status, triage (once
stabilized, based on risk of re-bleed) ulcers, erosive esophagitis/gastritis, and
MW Tear), IV octreoide (reduces portal
(in/outpatient), follow on care; High Risk- BP to lower risk of re-bleed)
ADMIT TO ICU!

Treatment Treatment -Meds

–First exclude Upper GI source.

 Which patients get tested? Complications

People over 60yrs.

dyspeptic, patients, chronic GERD, PUD

Dehydration, Hypokalemia, Metabolic

alkalosis, aspiration, aspiration, Boerhaave
syndrome (rupture of the esophagus), Mallory-
Weiss (bleeding secondary to a mucosal tear
at GE junction

Which patients get tested? Complications

 age 50 yrs or older, pts with severe paradoxical diarrhea, requires manual
constipation, signs of an organic disorder disimpaction, followed by oil-retention enema.

Which patients get tested? Complications

pts who have fever, elevated WBC (15,000 or

more), Bloody stool, Severe abd pain, profuse
watery diarrhea, dehydration, frail older
patients/nursing home residents,
immunocompromised pts, Abx exposure,
Hospital-acquired diarrhea, (onset after 3
days after admission), systemic illness,
tenesmus, presence or fecal lactoferrin
pts who have fever, elevated WBC (15,000 or
more), Bloody stool, Severe abd pain, profuse
watery diarrhea, dehydration, frail older
patients/nursing home residents,
immunocompromised pts, Abx exposure,
Hospital-acquired diarrhea, (onset after 3
days after admission), systemic illness,
tenesmus, presence or fecal lactoferrin

Which patients get tested? Complications

Which patients get tested? Complications
When do we refer? Diagnosis

When do we refer? Diagnosis

Symptoms are refractory to treatments, patient
has structural abnormality, evidence of
obstruction, Over age 50 or red flags (scope
referral)

When do we refer? Diagnosis

Less than 2 weeks duration

Watery, non-bloody
Usually mild, self-limited
Caused by a virus or noninvasive bacteria;
evaluation limited to Diarrhea that is severe/
Diarrhea that persists beyond 7 days
 Less than 2 weeks duration, Blood or pus, fever,
Usually caused by an invasive or toxin-producing
bacterium; TRAVELER'S DIARRHEA (develops during
travel or within 10 days of return)

When do we refer? Diagnosis

CARB MALABSORPTION: ID'ed by elimination trial;

MOTILITY: IBS, pain and altered bowel habits w/o
evidence of organic disease; ALL CHRONIC
DIARRHEA: First, rule out most common etiologies
Chronic diarrhea warrants GI referral (Meds, IBS Lactose intolerance), Evaluation
directed at most likely etiology based on symptoms
and history
 Essentials: Hematemesis, varying degrees of
hypovolemia, +/- melena/ hematochezia

When do we refer? Diagnosis

Hematochezia
Other Important Information

Other Important Information

 Other Important Information

Abx only recommended for: Shigellosis,

Cholera, Extraintenstinal salmonellosis,
listeriosis, traveler's diarrhea, C. Diff,
Giardiasis, Amebaiasis; ADMISSION: Severe
dehydration, bloody diarrhea, severe abd pain
(toxic colitis, IBD, intenstinal ischemia, surgical
abd), signs of infection or sepsis, older than 70,
immunocompromised, signs of hemolytic-
uremic syndrome)
 Abx only recommended for: Shigellosis,
Cholera, Extraintenstinal salmonellosis,
listeriosis, traveler's diarrhea, C. Diff,
Giardiasis, Amebaiasis; ADMISSION: Severe
dehydration, bloody diarrhea, severe abd pain
(toxic colitis, IBD, intenstinal ischemia, surgical
abd), signs of infection or sepsis, older than 70,
immunocompromised, signs of hemolytic-
uremic syndrome)

Other Important Information

Other inflmmatory conditions: Crohn,

Ulcerative Colitis; microscopic colitis; Systemic
Diseases: Thyroid disease, Diabetes
 High Risk Patients: Over 60yrs old, Comornid
illness, SBP less than 100mmHg, Pulse over
100bpm, Bright red blood in NG or upon rectal
examination; High Risk-ADMIT TO ICU!;
Benefits o endoscopy: -ID source of bleed,
determine risk of re-bleed, ability for
intervention: cautery, vasoconstrictive
injection, application of band/clip

Other Important Information

ALTHOUGH RARE, LGIB MAY LEAD TO

SIGNIFICANT BLOOD LOSS - ASSESS FOR
STABILITY FIRST!