Gastrointestinal Emergencies

Abstract

Oropharyngeal

• Neurological motility disorder: stroke; movement disorders (Parkinson’s disease, progressive supranuclear palsy); amyotrophic lateral sclerosis; multiple sclerosis; bulbar palsy; brainstem tumour; pseudobulbar palsy

• Striated muscle disease: myasthenia gravis; myotonic dystrophy; polymyositis; dermatomyositis; inflammatory myopathy; muscular dystrophy

• Reduced salivary flow leading to dry mouth (xerostomia): Sjogren’s syndrome; anticholinergics; antihistamines; ACE inhibitors; alpha-adrenergic blockers

• Structural lesions: inflammatory: pharyngitis, tonsillar abscess; head and neck tumours; pharyngeal diverticula; ulcerative stomatitis; painful glossitis; anterior marginal cervical osteophytes (especially with diffuse idiopathic skeletal hyperostosis)

• Metabolic: hypothyroidism; hyperthyroidism; steroid myopathy

Causes of dysphagia

Oropharyngeal

• Neurological motility disorder: stroke; movement disorders (Parkinson’s disease, progressive supranuclear palsy); amyotrophic lateral sclerosis; multiple sclerosis; bulbar palsy; brainstem tumour; pseudobulbar palsy

• Striated muscle disease: myasthenia gravis; myotonic dystrophy; polymyositis; dermatomyositis; inflammatory myopathy; muscular dystrophy

• Reduced salivary flow leading to dry mouth (xerostomia): Sjogren’s syndrome; anticholinergics; antihistamines; ACE inhibitors; alpha-adrenergic blockers

• Structural lesions: inflammatory: pharyngitis, tonsillar abscess; head and neck tumours; pharyngeal diverticula; ulcerative stomatitis; painful glossitis; anterior marginal cervical osteophytes (especially with diffuse idiopathic skeletal hyperostosis)

• Metabolic: hypothyroidism; hyperthyroidism; steroid myopathy

Oesophageal

• Solids & liquids (neuromuscular motility disorders)

  • Progressive: scleroderma; achalasia (progressive dysphagia for both solids and liquids; regurgitation of undigested food and saliva; chest pain; nocturnal cough and aspiration; minimal or no weight loss)
  • Intermittent: diffuse oesophageal spasm; presby-esophagus (nutcracker oesophagus)
• Solids only (mechanical obstruction)

  • Intermittent: lower oesophageal ring (Schatzki’s ring); hypertensive lower oesophageal sphincter
  • Progressive: peptic stricture (acid reflux due to gastro-oesophageal reflux disease); oesophageal cancer (progressive dysphagia, odynophagia, regurgitation, chest pain, weight loss, hoarseness of voice); foreign body impaction

Causes of mechanical obstruction

• Strictures

  • Benign (peptic): reflux oesophagitis
  • Malignant: carcinoma of oesophagus or gastric cardia

• Extrinsic compression: bronchial carcinoma; mediastinal lymph nodes; vascular compression; cervical osteoarthritis with vertebral osteophytes; mediastinal tumours

• Oesophageal web

• Foreign bodies (especially with pre-existing gastrointestinal abnormalities, such as diverticula, webs, rings): food bolus impaction; disc or button battery; coin (oesophageal coins are seen in a coronal alignment on an AP xray); toy parts, marbles

• Extrinsic compression: goitre with retrosternal extension; mediastinal tumours; large left atrium

Odynophagia

• Oesophagitis: infective (candidal; herpetic; cytomegalovirus); pill-induced (associated with oesophageal dysmotility, stricture or extrinsic compression) (tetracycline, doxycycline; potassium chloride; NSAIDs, aspirin; alendronate); corrosive (caustic ingestion); radiation induced

• Oesophageal ulcer

Dysphagia checklist

• Evidence of weight loss

• Anaemia

• Hoarseness of voice

• Oral ulceration; signs of candidiasis

• Cervical lymphadenopathy

• Bulbar signs

• Chest signs

Features of caustic ingestion

• Oedema of the lips, tongue and palate

• Oropharyngeal burns

• Drooling of saliva

• Dysphagia

• Nausea and vomiting

• Haematemesis

• Shortness of breath

• Stridor

• Abdominal pain

Features of neurogenic dysphagia

• Drooling of saliva

• Difficulty in initiating swallowing

• Nasal regurgitation

• Choking or coughing while feeding

• Food sticking in the throat

• Nasal tone to speech

• Aspiration, with recurrent pneumonia

Features of oropharyngeal dysphagia

• Solids handled better than liquids

• Difficulty initiating swallowing

• Cough and choking during and after swallowing

• Nasal regurgitation of liquids

• Hesitancy and repeated attempts at the inititation of swallowing

• Food sticking in throat

• Nasal speech

• Changes in the character of the voice

• Constant drooling of saliva

Features of oesophageal dysphagia

• Sensation of food sticking in chest or throat after swallowing

• Recurrent pneumonia

• Gastro-oesophageal reflux disease: heartburn; belching; sour regurgitation; waterbrash

Red flags for dysphagia

• Progressive painless dysphagia

• Unintentional weight loss

• Persistent vomiting

• Haematemesis

• Hoarseness of voice

• Systemic symptoms: fever, night sweats

• Bulbar neurological signs

• Cervical lymphadenopathy

Risk factors for oesophageal cancer

• Age >70 years

• Smoking

• Alcohol consumption (SCC)

• Dietary factors

• Barrett oesophagus

• Gastro-oesophageal reflux disease (adenocarcinoma)

• Excessive ingestion of very hot liquids (SCC)

• Caustic ingestion (SCC)

• Achalasia (SCC)

• Plummer-Vinson syndrome (SCC)

Dysphagia evaluation checklist

• All: FBC, U&E, LFTs, bone profile, CXR (mediastinal widening, absence of gastric air bubble, extrinsic mass)

• Oropharyngeal: direct laryngoscopy; video fluoroscopy

• Oesophageal: endoscopy; barium swallow; oesophageal manometry

Possible presentations of gastro-oesophageal reflux disease

• Gastrointestinal: heartburn; regurgitation; waterbrash; globus sensation of lump in neck or throat; dysphagia (erosive oesophagitis; peptic stricture (intermittent solid food dysphagia in a patient with heartburn); adenocarcinoma of oesophagus); odynophagia; hiccups; epigastric pain, dyspepsia; vomiting; erosion of dental enamel

• Pulmonary: chronic nocturnal cough; asthma; sleep apnoea; aspiration; recurrent pneumonia; interstitial pulmonary fibrosis; acute life-threatening episodes

• ENT: sore throat; hoarseness; laryngitis; chronic sinusitis; vocal cord granulomas; sub-glottic stenosis

• Atypical chest pain

• Dystonic movements: Sandifer’s syndrome (gastro-oesophageal reflux associated with torsional dystonia of the head, neck, eyes and trunk, and opithostonic posturing)

Risk factors for gastro-oesophageal reflux

• Smoking

• Alcohol ingestion

• Obesity

• Drugs: NSAIDs; calcium channel blockers; nitrates; benzodiazepines

• Systemic disease: diabetes mellitus with autonomic neuropathy; scleroderma

• Sleep apnoea

Causes of odynophagia

• Infectious oesophagitis

• Gastrooesophageal reflux/stricture

• Pill-induced ulceration

• Radiation oesophagitis

• Caustic stricture

• Foreign body

• Cancer

Causes of infective oesophagitis

• Fungal infections: candida albicans

  • Risk factors
  • Immunocompromised: HIV infection; transplant recipient; immunosuppressive therapy
  • Immunocompetent: prolonged antibiotic therapy; acid suppressive therapy; oesophageal motility disorders; diabetes mellitus; head and neck radiation therapy

• Viral infections: herpes simplex; cytomegalovirus; Epstein-Barr virus

• Bacterial infections

• Protozoal infections

Abdominal pain mechanisms

• Peritoneal irritation

• Visceral obstruction

• Visceral ischaemia

• Visceral inflammation

• Abdominal wall pain

• Referred pain

Patterns of abdominal pain

Parietal: irritation of parietal peritoneum

• Pain in dermatome distribution

• Well localised

• Sharp

• Clear onset

Visceral: stretch, distension, contraction (spasm), compression or torsion of a hollow viscus

• Referred pain in embryonic distribution

• Poor localisation

• Dull and aching

• Insidious onset

Referred

Dermatomal perception of visceral pain

Organ	Site of pain	Dermatomes
Stomach	Epigastrium	T6-T10
Small bowel	Umbilical	T9-T10
Gallbladder	Epigastrium	T7-T9
Pancreas	Epigastrium	T6-T10
Colon up to splenic flexure	Umbilical	T11-L1
Colon from splenic flexure	Hypogastrium	L1-L2
Testis and ovary	Umbilical	T10-T11

Causes of abdominal pain

(the site of origin of pain may be related to the source of the underlying causative pathology)

Diffuse pain

• Aortic aneurysm: leaking; ruptured

• Aortic dissection

• Early appendicitis

• Bowel obstruction

• Diabetic gastric paresis; diabetic ketoacidosis

• Gastroenteritis (vomiting precedes abdominal pain)

• Heavy metal poisoning

• Hereditary angioedema

• Mesenteric ischaemia

• Volvulus

• Metabolic disorder: Addisonian crisis, ketoacidosis (diabetic, alcoholic), acute intermittent porphyria (attacks of severe diffuse abdominal pain, associated with nausea and vomiting, constipation, muscle weakness, urine retention, and sometimes confusion, hallucinations and seizures; increased urine delta-aminolaevulinic acid and porphobilinogen; atatcks may be precipitated by hormonal changes, drugs, reduced calorie intake, alcohol, and emotional stress), uraemia

• Opioid withdrawal

• Pancreatitis

• Perforated bowel

• Peritonitis from any cause

• Sickle cell crisis

• Malaria

• Familial Mediterranean Fever

Abdominal wall pain (Carnett sign: pain is increased on tensing abdominal wall by lifting head and shoulders off the examination table while supine)

• Spiegelian, incisional hernia

• Rectus sheath haematoma (abdominal wall mass with bruising; risk factors include old age, anticoagulant therapy, trauma, injection procedures, physical exercise, and raised intra-abdominal pressure fro coughing, sneezing or vomiting)

• Muscle strain

Right upper quadrant pain

• Biliary disease: Biliary colic; acute cholecystitis (Murphy’s sign of inspiratory arrest due to pain on inspiration during right subcostal palpation with hand or ultrasound probe; jaundice in 20–25% cases); choledocholithiasis, cholangitis

• Hepatic disease: acute hepatitis; liver abscess; hepatic congestion; liver tumour

• Perihepatitis (Fitzhugh-Curtis syndrome): may be associated with signs of salpingitis

• High retrocaecal appendicitis; appendicitis complicating pregnancy

• Perforated duodenal ulcer

• Perinephritis

• Pulmonary: right lower lobe pneumonia; pleuritis; pulmonary embolism; empyema

• Myocardial ischaemia

• Herpes zoster

Causes of tender palpable right subcostal mass

Empyema of gallbladder (suppurative cholecystistis).

Gall bladder perforation with abscess

Omental phlegmon

Carcinoma of the gall bladder

Risk factors for cholesterol gallstones

Increased bile cholesterol concentration

• Increasing age

• Female gender

• Obesity

• Pregnancy and multiparity

• Rapid weight loss (>1.5 kg/week), including during treatment for morbid obesity

• Hypertriglyceridaemia

• Low LDL cholesterol

• Diabetes mellitus

• Drugs: oestrogens, octreotide, ceftriaxone

Reduced bile acid pool

• Ileal disease (Crohn’s disease; terminal ileal resection/ bypass)

• Primary biliary cirrhosis

Hepato-biliary causes of right upper quadrant pain in pregnancy

Not unique to pregnancy

• Viral hepatitis

• Budd-Chiari syndrome

• Hepatic malignancy

• Biliary colic

• Choledocholithiasis

• Cholangitis

• Cholecystitis

Unique to, or highly associated with, pregnancy

• Pre-eclampsia or eclampsia

• HELLP (haemolysis, elevated liver enzymes and low platelet count) syndrome (third trimester)

• Acute fatty liver of pregnancy

• Hepatic haemorrhage or rupture

• Symptomatic choledochal cysts

Left upper quadrant pain

• Splenic: splenic rupture/distension; splenic infarction; splenomegaly (spontaneous splenic rupture can present with referred left shoulder pain from diaphragmatic irritation-Kehr’s sign, and a tender left upper quadrant mass-Ballance’s sign, and is associated with infections (infectious mononucleosis and malaria) and haematological malignancy (lymphoma and leukaemia)

• Ruptured splenic artery aneurysm

• Gastritis

• Perforated gastric ulcer

• Jejunal diverticulitis; diverticulitis affecting the splenic flexure

• Pancreatitis

• Pulmonary: left lower lobe pneumonia; pleuritis; empyema

• Cardiac: pericarditis; myocardial ischaemia

• Herpes zoster

Right lower quadrant pain

• Colonic: acute appendicitis; acute enterocolitis; caecal diverticulitis; colonic obstruction; torsion of appendices epiploicae; epiploic appendagitis

• Small bowel: Crohn’s disease (terminal ileitis); Meckel’s diverticulitis; small bowel obstruction; intusussception (triad of vomiting, abdominal pain and currant jelly stools)

• Foreign body perforation

• Mesenteric adenitis

• Perforated peptic ulcer

• Gynaecological: ovarian cyst accident (including mittelschmerz)- rupture, torsion; endometriosis; pelvic inflammatory disease(salpingitis); ectopic pregnancy

• Cholecystitis

• Vascular: aortic aneurysm: leaking; ruptured; ruptured iliac artery aneurysm

• Renal: renal/ureteric colic; pyelonephritis

• Psoas abscess

• Inguinal hernia: incarcerated; strangulated

• Testicular torsion

• Seminal vesiculitis

• Rectus sheath haematoma

• Herpes zoster

Left lower quadrant pain

• Colonic: diverticulitis (sigmoid); acute appendicitis (with situs inversus); perforated colonic cancer; Crohn’s colitis; ischaemic colitis; colonic obstruction

• Vascular: aortic aneurysm: leaking; ruptured; ruptured iliac artery aneurysm

• Gynaecological: ovarian cyst accident (including mittelschmerz),-torsion, rupture); endometriosis;pelvic inflammatory disease(salpingitis); ectopic pregnancy

• Renal: renal/ureteric colic; pyelonephritis

• Psoas abscess

• Testicular torsion

• Inguinal hernia: incarcerated; strangulated

• Seminal vesiculitis

• Rectus sheath haematoma

• Herpes zoster

Potential causes of non-specific abdominal pain

(diagnosis of exclusion)

• Viral infection

• Parasitic infestation

• Gastroenteritis

• Mesenteric adenitis

• Ovulatory pain

• Lesions of appendices epiploicae of colon

Medical causes of acute abdominal pain

• Intra-thoracic: inferior ST elevation myocardial infarction; pericarditis; lower lobe pneumonia; pulmonary embolism; oesophageal disease

• Endocrine/ metabolic: diabetic ketoacidosis; acute adrenocortical insufficiency; acute intermittent porphyria; hyperlipidaemia; Familial Mediterranean Fever

• Drug induced: opioid withdrawal; lead poisoning

• Haematological: sickle cell crisis; acute leukaemia

• Central nervous system: pre-eruptive phase of herpes zoster; spinal nerve root compression

Causes of peritonitis

• Hollow viscus perforation: stomach (gastric ulcer; gastric cancer); duodenum (duodenal ulcer); small bowel (mesenteric ischaemia and infarction); colon (divericulitis; cancer; inflammatory bowel disease); appendix (appendicitis); gallbladder (cholecystitis)

• Abdominal trauma: blunt; penetrating

• Foreign body ingestion

• Anastomotic leakage

• Spontaneous bacterial peritonitis: ascites from portal hypertension; nephrotic syndrome

• Pelvic inflammatory disease

Abdominal pain evaluation

History

SOCRATES to characterize pain (allow the patient to describe the pain initially without any leading questions)

• Site and duration

• Onset: sudden versus gradual; sudden onset suggests a vascular emergency (mesenteric ischaemia; ruptured abdominal aortic aneurysm), volvulus, intestinal perforation or torsion of hollow viscus

• Character: sharp, dull, aching, colicky, burning

• Radiation: shoulder, back, groin or testicle

• Timing: intermittent, constant

• Exacerbating (aggravating factors): movement (worsens pain in peritonitis), position, food, medications, and alleviating factors: rest.

• Severity

Associated symptoms: fever; nausea and vomiting; diarrhoea/constipation; haematemesis/ melaena; fresh rectal bleeding; dysuria/ haematuria

Physical examination checklist

• Vital signs; tachypnoea may be related to metabolic acidosis, hypoxaemia, or catecholamine-induced pain response; signs of hypovolaemia: tachycardia, postural hypotension

• Localisation of maximal tenderness and guarding

• Signs of peritonitis: tenderness, guarding (abdominal wall rigidity), percussion tenderness, rebound tenderness (gentle depression of the abdominal wall for 15 to 30 minutes, followed by sudden release of pressure), generalised ileus, fever

• Specific signs: Carnett’s sign: increased pain on tensing abdominal wall when a supine patient lifts the head and shoulders off the bed; Murphy’s sign: inspiratory arrest on deep palpation of right upper quadrant; psoas sign (passive hip extension is painful, with the patient in the lateral decubitus position); Rovsing’s sign (pressure in the left lower quadrant produces rebound pain in the right lower quadrant on release of the pressure); obturator sign (flexion with external and internal rotation of the hip is painful)

• Abdominal mass

• Aortic tenderness or enlargement (bedside ultrasound may be useful)

• Hernial orifices

• External genitalia

• Bowel sounds: absent; normal; hyperactive; tinkling

• Rectal examination

• Bimanual pelvic examination

Special considerations with assessment of acute abdominal pain in the elderly

• Difficulty in obtaining a history caused by impaired cognitive function (eg dementia)

• Atypical presentations

• Lack of typical clinical findings (eg peritonitis without peritonism)

• Multiple co-morbidities

• Medications that block physiological responses leading to difficulty in assessment (eg beta-blockers)

• Decreased immune function, leading to increased severity of disease

Causes of acute abdominal pain and shock (indicative of hypovolaemia and/or sepsis)

• Perforated hollow viscus: perforated peptic ulcer

• Massive haemorrhage: spontaneous splenic rupture; leaking abdominal aortic aneurysm; ruptured ectopic pregnancy

• Acute arterial occlusion: mesenteric accident (superior mesenteric artery embolism/ thrombosis, mesenteric venous thrombosis, non-occlusive mesenteric ischaemia); strangulation obstruction

• Third space losses of fluid: acute pancreatitis

• Cardiac: acute inferior STEMI

Causes of haemoperitoneum

• Trauma: penetrating; blunt (liver, spleen)

• Vascular accident: ruptured aneurysm of abdominal aorta, splenic artery, or iliac artery

• Gynaecological: ruptured ectopic pregnancy; ruptured ovarian cyst (follicular cyst; endometriotic cyst)

• Ruptured intra-abdominal neoplasm: hepatocellular carcinoma; hepatic adenoma; pelvic tumours (malignant ovarian masses; uterine sarcomas)

• Spontaneous rupture of spleen

• Anticoagulant therapy

Causes of referred abdominal pain

• Cardiac: inferior STEMI; congestive heart failure with hepatic congestion

• Pulmonary: lower lobe pneumonia; pulmonary embolism

Presentations of ruptured abdominal aortic aneurysm

(infra-renal aortic diameter 3 cm or more)

• Triad of abdominal, flank or back pain, acute hypotension and pulsatile abdominal mass; a tender aneurysmal mass is indicative of an aortic emergency

• Ureteric colic

• Rupture into inferior vena cava (aorto-caval fistula): high-output congestive heart failure

• Rupture into duodenum (aorto-duodenal fistula): upper gastrointestinal bleeding

• Acute testicular pain and bruising

• Inguinoscrotal mass mimicking hernia

• Rupture into left renal vein: massive haematuria

• Iliofemoral venous thrombosis from ilio-caval compression

• Acute lower limb ischaemia

• Chronic contained rupture, with lumbar neuropathy

Other potential presentation of abdominal aortic aneurysm:

• Duodenal compression

• Hydronephrosis

• Ureteric obstruction and renal pain

• Thrombo-embolic phenomena: femoral; popliteal; microemboli(trash foot: tip necrosis of toes; small punctate pretibial ischaemic lesions

• Acute thrombosis, resembling saddle embolus

Bedside ultrasound diagnosis of abdominal aortic aneurysm

Abdominal aortic aneurysm is dilatation of the aorta greater than 3 cm or 1.5 times the normal diameter for that person

Maximum aortic diameters at different levels

• Level of diaphragm 2.5 cm

• Level of renal arteries 2 cm

• Bifurcation 1.5–2 cm

• Iliac arteries just distal to the bifurcation 1 cm

Atypical presentations of acute appendicitis

• Acute right upper quadrant or loin pain: retro-caecal or retro-colic appendicitis

• Gastroenteritis: diarrhea and vomiting: pre-and post-ileal appendicitis

• Acute right lower quadrant pain with psoas irritation

• Acute small bowel obstruction

• Dysuria and pyuria; microscopic haematuria: sub-caecal and pelvic appendicitis

Alvarado Score (MANTRELS) for diagnosis of acute appendicitis

SYMPTOMS

• Migration of pain to the right lower quadrant = 1

• Anorexia = 1

• Nausea or vomiting = 1

SIGNS

• Tenderness in the right lower quadrant = 2

• Rebound tenderness = 1

• Elevated temperature: fever of 37.3 C or more = 1

LABORATORY TESTS

• Leukocytosis >10,000 white blood cells per microlitre in the serum = 2

• Left shift of leukocytes = 1

• Total = 10

• Score

• 5 or 6: Compatible with the diagnosis of acute appendicitis

• 7 or 8: Probable appendicitis

• 9 or 10: Very probable acute appendicitis

Investigations for abdominal pain

• Venous blood: full blood count, urea and electrolytes, CRP, liver function tests (right upper quadrant pain), amylase/lipase, glucose; blood gas analysis

• 12 lead ECG

• Ultrasound/CT

• Urine dipstick

• Urine beta-HCG (all women of child bearing age)

Red flags for abdominal pain

• Severe pain

• Signs of shock

• Abdominal distension

• Signs of peritonitis

• Failed initial treatment

• Haemodynamic disturbance

Causes of loin pain

• Renal: pyelonephritis; calculus; neoplasm; infected obstructed kidney; abscess; infarction; pelvi-ureteric obstruction

• Aortic: leaking aneurysm; dissection

• Radiculopathy

• Muscle strain

• Herpes zoster

• Retroperitoneal fibrosis

Causes of hyperamylasemia

(rises 2–12 h after initiating insult, and remains elevated 3–5 days).

Pancreatic causes

• Acute pancreatitis; acute exacerbation of chronic pancreatitis

• Pancreatic cancer

Non-pancreatic intra-abdominal emergencies

• Ruptured ectopic pregnancy

• Peritonitis

• Perforated hollow viscus (peptic ulcer disease with perforation

• Intestinal obstruction

• Mesenteric ischaemia/infarction

• Biliary tract disease; acute cholecystitis; choledocholiathiasis

• Aortic dissection

• Acute appendicitis

• Acute salpingitis

Miscellaneous

• Salivary gland disease

• Pregnancy

• Tumour

• Burns

• Renal disease: chronic kidney disease

• Diabetes ketoacidosis

• Macroamylasaemia

Features of acute pancreatitis

• Sudden onset of upper abdominal pain, radiating to the mid-thoracic area of the back; continuous, severe, reduced on sitting up or leaning forwards

• Nausea and vomiting

• Upper abdominal distension

• Low grade fever (high fever indicates infected pancreatic necrosis or coexistent cholangitis)

• Epigastric tenderness

• Paralytic ileus, with absent bowel sounds

• Intravascular volume depletion due to retroperitoneal fluid loss: hypovolaemic shock

• Ecchymoses around the umbilicus and in the flanks, associated with severe haemorrhagic pancreatitis

• Signs of peritoneal irritation

• Painless pancreatitis can be seen in patients undergoing peritoneal dialysis or following renal transplantation

• Serum amylase or lipase is at least three times greater than the upper limit of normal. Lower diagnostic levels are associated with delayed presentation and with relapsing acute pancreatitis, where there is loss of pancreatic exocrine cell mass; lipase is a preferable investigation. The absolute level does not correlate with severity of the underlying disease.

Causes of acute pancreatitis

• Toxic/metabolic

  • Chronic alcohol abuse
  • Toxic alcohols
  • Metabolic: hypertriglyceridaemia; hypercalcaemia
  • Toxins: scorpion venom; snake venom
• Obstructive causes (biliary tract disease)

  • Gallstones; ampullary obstruction (carcinoma, adenoma, peri-ampullary diverticulum)
  • Structural abnormalities: choledochocele; pancreas divisum; annular pancreas

• Abdominal trauma: penetrating/blunt (bicycle handlebar injury to upper abdomen)

• Penetrating peptic ulcer

• Drugs: thiazide diuretics; glucocorticoids; immunosuppressants (azathioprine, 6-mercaptopurine); oestrogens; gliptins; anti-epileptic drugs (valproate)

• Necrotising vasculitis: systemic lupus erythematosus, thrombotic thrombocytopenic purpura

• Infections: viral (mumps; cytomegalovirus; Epstein-Barr virus; varicella-zoster virus); bacterial (mycobacteria); parasitic (Ascaris lumbricoides; liver flukes-Clonorchis sinensis; Fasciola hepatica)

• Eating disorders: anorexia; bulimia

• Iatrogenic: post-ERCP; post-sphincterotomy

• Hereditary

• Idiopathic

Adverse prognostic features on admission with acute pancreatitis (modified Glasgow criteria)

• Age >55 years

• Pa02 on room air <8 kPa

• White cell count >15,000/cu mm

• Glucose >10.0 mmol/L

• Serum calcium <2.0 mmol/L

• Serum albumin <32 g/dl

• Enzymes: aspartate transaminase >250 IU/L; lactate dehydrogenase >600 IU/L

• Serum urea nitrogen >16.1 mmol/L

Causes of mesenteric ischaemia

Occlusive

• Arterial: embolism (cardiac or aortic emboli-usually from mural thrombus in left atrium or left ventricle); thrombosis (atherosclerosis; aortic aneurysm; aortic dissection)

• Venous: thrombosis-hypercoagulable states (neoplasm, oral contraceptive pill, thrombophilia, thrombocytosis, polycythaemia vera); intra-abdominal sepsis with portal pyaemia; pancreatitis; malignancy; portal hypertension

• Strangulation: adhesive band; volvulus; internal hernia; intusussception

Non-occlusive: low-flow states with hypotension (congestive heart failure, cardiogenic shock, septic shock); vasopressor therapy; drug-induced mesenteric vasoconstriction (cocaine, alpha-agonists, beta blockers, ergotamines).

Features of mesenteric ischaemia

• Age usually over 60 years

• Sudden onset of severe diffuse abdominal pain out of proportion to findings on physical examination and unresponsive to opiate analgesia

• Nausea, vomiting, diarrhoea (“gut emptying”)

• Later development of peritoneal signs secondary to generalized peritonitis associated with bowel infarction

• Gastrointestinal bleeding

• A preceding history of post-prandial abdominal discomfort (abdominal angina), food avoidance and weight loss may indicate pre-existing chronic mesenteric ischaemia, with superimposed thrombosis. Typically, abdominal discomfort occurs 10–15 min after eating, and lasts from one to 4 h.

• Leukocytosis

• Metabolic acidosis with high anion gap and elevated venous lactate

Risk factors for mesenteric arterial embolism

• Cardiac arrhythmias: atrial fibrillation; atrial flutter

• Post-myocardial infarction: mural thrombus; ventricular aneurysm

• Valvular heart disease: mitral stenosis; infective endocarditis

• Structural heart defects: right-to-left intracardiac shunts

• Dilated cardiomyopathy

• Iatrogenic: post-angiography or endovascular procedures

Acute gastroenteritis syndromes

(triad of diarrhea, vomiting and fever).

Bloody diarrhoea

• Invasive bacterial pathogens: Salmonella enterica serotypes; Campylobacter jejuni; Shigella; Entero-invasive Escherichia coli; Entero-haemorrhagic E. coli; Yersinia enterocolitica; Clostridium difficile

• Protozoal: Entamoeba histolytica; Balantidium coli

• Miscellaneous: Schistosoma mansoni; Trichuris trichiura

Acute watery diarrhoea

• Viruses: rotavirus; enteric adenoviruses; calciciviruses; astroviruses; coronaviruses; Norwalk agent

• Preformed bacterial toxin (symptoms within 6 hours of ingestion): Salmonella enterica serotypes; Campylobacter jejuni; Entero-pathogenic Escherichia coli; Entero-toxigenic E.coli; Entero-aggregative E.coli; Vibrio cholerae; Vibrio parahaemolyticus; Clostridium difficile; Staphylococcus aureus(toxin b); Bacillus cereus; Yersinia enterocolitica

• Protozoa: Giardia lamblia; Cryptosporidium parvum; Isospora belli; Cyclospora cayetanensis; Dientamoeba fragilis; Entamoeba histolytica

• Non-infective: food allergy/intolerance (cow’s milk protein intolerance; lactose intolerance); chemotherapy/ radiation therapy

Persistent diarrhoea

• Viruses: recurrent infections with rotavirus

• Bacteria: Mycobacterium tuberculosis; recurrent and relapsing infections with other bacterial pathogens

• Protozoa: Giardia lamblia; Entamoeba histolytica; Cryptosporidium parvum; Isospora belli; Cyclospora cayetanensis

• Miscellaneous: post-infectious irritable bowel syndrome; disaccharidase deficiency

Mechanisms of infective diarrhoea

• Non-inflammatory, or secretory, diarrhoea

  • Viral infections: Rotavirus, Norwalk agent, astrovirus
  • Vibrio cholerae
  • Preformed toxins: Staphylococcus aureus, Bacillus cereus
  • Parasites: Giardia lamblia, Cryptospo-​ridium parvum, Isospora belli
• Inflammatory diarrhea (dysenteric syndromes) (small volume bloody diarrhea, lower abdominal cramps, faecal urgency, tenesmus, fever)

  • Bacterial dysentery: Shigella, Salmonella, Escherichia coli 0157, Campylobacter
  • Amoebic dysentery

• Invasive gastrointestinal infections (enteric fever syndromes)

Potential sources of food poisoning

• Campylobacter: raw or undercooked meat (especially poultry); unpasteurised milk; untreated water

• Salmonella: raw or undercooked meat; raw eggs, milk, and other dairy products

• Listeria: chilled “ready-to-eat” foods, including cooked sliced meats and pate, soft cheeses (Brie, Camembert, feta); and pre-packed sandwiches

• Escherichia coli: undercooked beef (especially mince, burgers, meatballs); unpasteurised milk; contaminated raw leaf green vegetables

• Bacillus cereus: fried rice dishes sitting at room temperature (eg in a buffet)

• Vibrio cholerae and vibrio parahaemolyticus: contaminated water; undercooked seafood (fish and shellfish)

• Norovirus: person-to-person spread, through contaminated food or water; raw shellfish (especially oysters)

Risk factors for complications following acute gastroenteritis

• Age 60 years or older

• Pregnancy

• Co-morbidities: immunosuppression; chronic kidney disease; inflammatory bowel disease; diabetes mellitus; connective tissue diseases; gastric achlorhydria (proton pump inhibitor or histamine 2 receptor antagonist treatment)

Causes of blood in the stool associated with diarrhoea

Infectious colitis

• Campylobacter

• Escherichia coli 0157

• Shigella

• Salmonella

Inflammatory bowel disease

• Ulcerative colitis (severity can be graded by Truelove and Witts’ severity index into mild, moderate and severe)

• Crohn’s disease

Risk factors for infectious colitis

• Antimicrobial therapy: broad spectrum antibiotics

• Immunodeficiency: HIV; cancer chemotherapy

• Enteropathogen exposure: travel to the developing world; food and water contamination; water sports

• Extremes of age: infancy; elderly

• Gastric achlorhydria; proton pump inhibitor therapy

Acute presentations of inflammatory bowel disease

• Bloody diarrhoea

• Acute right lower quadrant abdominal pain

• Lower gastrointestinal bleeding

• Acute small bowel or large bowel obstruction

• Bowel perforation; intra-abdominal abscess

• Toxic megacolon: a life-threatening complication with systemic toxicity; abdominal distension; bloody diarrhoea; signs of peritonitis; septic shock; acute dilatation of the colon (usually transverse colon) to a diameter of 6 cm or greater, with loss of haustral markings, thumbprinting from haustral thickening at regular intervals (caused by mucosal oedema) and pseudopolyps

• Perianal disease: abscess; fistula; fissure (wide, deep, with undermined edges, multiple, often lateral to the midline)

• Extra-intestinal manifestations: erythema nodosum; acute red eye (iritis, episcleritis); acute arthritis; pyoderma gangrenosum

Criteria for severe ulcerative colitis

• More than 6 bowel movements per day

• Temperature >37.8 degrees Centigrade

• Heart rate >90 beats per minute

• Haemoglobin <10.5 g/dl

• ESR >30 mm/hour

Causes of toxic megacolon

• Inflammatory bowel disease: ulcerative colitis; Crohn’s disease

• Infectious colitis: bacterial (Clostridium difficile; Salmonella; Shigella; Campylobacter; Yersinia; Pseudomonas); viral (cytomegalovirus); parasitic (amoebic colitis; Cryptosporidium)

• Ischaemic colitis

• Obstructing colon cancer

Risk factors for clostridium difficile colitis

• Age >65 years

• Antibiotic therapy: clindamycin; cephalosporins, fluoroquinolones

• Immunosuppression

• Gastric acid suppression: proton pump inhibitors; H2-receptor blockers

• Gastrointestinal tract surgery

• Colonic disease: colorectal cancer; inflammatory bowel disease

• Previous Clostridium difficile infection

• Chemotherapy for haematological and solid organ malignancy

Causes of Traveller’s diarrhoea

• Gram negative bacilli: Enterotoxigenic Escherichia coli; Salmonella species; Shigella species

• Curved motile Gram negative bacilli: Vibrio species; Campylobacter species; Plesiomonas shigelloides; Aeromonas hydrophila

• Protozoa: Entamoeba histolytica; Giardia lamblia; Cryptosporidium

• Viruses: Norwalk agent

Mechanisms of diarrhoea

Osmotic (high osmotic load of intraluminal content)

• Lactase deficiency

• Disaccharidase deficiencies

• Magnesium induced

• Short bowel

• Extensive mucosal disease: celiac disease; Crohn’s disease

• Bile salt malabsorption

• Pancreatic insufficiency

• Drugs, eg lactulose

Secretory (active chloride secretion)

• Toxins: cholera; clostridium

• Excess gut hormones

• Stimulant laxatives

• Bacterial overgrowth

• Inflammatory bowel disease

• Diabetic neuropathy

• Villous adenoma of the rectum

• Carcinoma of the rectum

• Neural crest tumours, eg carcinoid, VIPoma

Dysmotility

• Functional bowel disease

• Endocrine disorders

• Autonomic neuropathies

Inflammatory

• Infections

• Inflammatory bowel disease

• Ischaemic bowel disease

Diarrhoea and vomiting checklist

• The presence of blood in the stool indicates an invasive infection

• Volume of stool: large volume watery diarrhea, diffuse abdominal cramps, bloating and borborygmi (bowel sounds audible at a distance) indicate small bowel disease, while small volume bloody diarrhea with lower abdominal cramping and tenesmus (sensation of incomplete bowel evacuation) indicates large bowel disease

• Travel history

• Exposure history: exposure to a known source of enteric infection (contaminated food or water)-eating meals out, farm visit; contacts who are ill

• Ingestion of specific dietary items during food-borne outbreaks: dairy products; eggs; chicken; seafood

• Recent hospitalization or antimicrobial use: consider Clostridium difficile

• Risk factors for HIV infection and other co-morbid illnesses resulting in immunosuppression, including cancer chemotherapy, will lead to a wider differential diagnosis

Causes of flushing and diarrhoea

• Anxiety attacks

• Diabetic autonomic neuropathy

• Thyrotoxicosis

• Carcinoid syndrome

• Phaeochromocytoma

• Systemic mastocytosis

Causes of faecal incontinence

(involuntary loss of solid or liquid faeces of flatus)

• Constipation; faecal impaction with overflow incontinence

• Diarrhoea: gastroenteritis; inflammatory bowel disease; irritable bowel syndrome

• Obstetric injury to the pelvic floor: instrumental vaginal delivery; third degree perineal tear with sphincter involvement; prolonged second stage of labour; large baby; occipito-posterior presentation

• Post-gastrointestinal surgery: colectomy with ileoanal anastomosis; internal anal sphincterotomy for chronic anal fissure; haemorrhoidectomy; anal dilatation

• Neurological causes: spinal cord injury; multiple sclerosis; spina bifida; stroke

• Post radiation for pelvic cancer

• Congenital anorectal anomalies

Causes of constipation

Features:

• Hard pellet-like stools

• Infrequent defaecation

• Excessive straining at stool with difficulty in evacuation (dyschezia)

Dietary factors: insufficient dietary fibre (low residue diet); insufficient fluid intake (dehydration).

Motility disorders: irritable bowel syndrome; idiopathic slow transit

Drugs:

• Aluminium- and calcium- containing antacids

• Tricyclic antidepressants

• Anti-cholinergic agents: amitriptyline

• Iron supplements

• Opioid analgesics: codeine, dihydrocodeine, morphine

• Lead poisoning

• Long-term laxative abuse

• Anti-Parkinsonian agents

• Phenothiazines

• Diuretics

• Calcium channel blockers: verapamil

• Beta blockers

• Calcium supplements

Metabolic/endocrine diseases:

• Hypercalcemia; hypomagnesemia

• Diabetic autonomic neuropathy

• Hypothyroidism

• Hypokalemia

• Uraemia

Anorectal disease:

• Painful anal conditions: anal fissure; anorectal abscess; thrombosed haemorrhoids; proctitis

• Pelvic outlet syndrome

Colonic obstruction

• Colorectal carcinoma

• Benign colonic stricture (diverticular; ischaemic)

• Myenteric plexus aganglionosis-Hirschsprung’s disease(congenital); Chagas disease(acquired)

• Chronic intestinal pseudo-obstruction

• Faecal impaction

Neurological conditions

• Spinal cord injury

• Cerebrovascular disease

• Multiple sclerosis

• Parkinson’s disease

Immobility and lack of exercise

Depression

Red flag symptoms in constipation

• New onset of severe constipation or recent change of bowel habit in elderly patient

• Rectal bleeding

• Unexplained anaemia

• Family history of colorectal cancer or inflammatory bowel disease

• Tenesmus

• Weight loss

• Vomiting

Rome II criteria for constipation

Adults

Two or more of the following for at least 12 weeks in the preceding 12 months:

• Straining during >25% of bowel movements

• Lumpy or hard stools for >25% of bowel movements

• Sensation of incomplete evacuation for >25% of bowel movements

• Sensation of anorectal blockage for >25% of bowel movements

• Manual manoeuvres to facilitate >25% of bowel movements

• <3 bowel movements per week

• Loose stools not present, and insufficient criteria for irritable bowel syndrome met

Evaluation of constipation

• Digital rectal examination

• Full blood count

• Serum calcium

• Thyroid function tests

Features associated with faecal impaction

• Diarrhoea

• Faecal incontinence

• Urinary frequency/incontinence

• Rectal pain

• Abdominal pain

• Large bowel obstruction

Risk factors

• Immobility

• Inadequate diet

• Medication: opiates; anticholinergic agents

• Chronic kidney disease

Causes of small bowel obstruction

(colicky abdominal pain, nausea, vomiting-often bilious, diarrhoea, and later constipation).

Adynamic ileus: generalised peritonitis (perforated viscus); acute pancreatitis; postoperative ileus; electrolyte disease; intra-abdominal infection; acute diverticulitis; acute appendicitis; pelvic inflammatory disease

Mechanical obstruction

• Luminal: gallstone ileus (Rigler’s triad of mechanical small bowel obstruction, pneumobilia and ectopic gallstone within the intestinal lumen); neoplasm; bezoar; foreign body; parasites

• Intramural (in the bowel wall): Meckel’s diverticulum; Crohn’s disease; neoplasm (leiomyoma carcinoid, adenocarcinoma); intussusception (triad of pain, currant jelly stool and palpable sausage-shaped abdominal mass –in 20 to 25% of children); volvulus; radiation enteritis; haematoma; ischaemic stricture

• Extrinsic: post-operative adhesions; incarcerated groin (inguinal or femoral) hernia; obturator hernia (acute small bowel obstruction, associated with medial thigh pain due to obturator nerve compression in the obturator canal, often in frail elderly women-Howship-Romberg sign); abscess; metastatic disease; congenital bands

Risk factors for intraperitoneal adhesions

• Open abdominal or pelvic surgery

• Peritonitis

• Foreign body: talc, starch, cellulose

• Inflammatory bowel disease

• Radiation enteritis

• Sclerosing peritonitis (drug-induced: beta blocker)

Radiological features of small bowel obstruction

• Multiple central dilated loops of bowel (>3 cm in diameter, measured outer wall to outer wall)

• Valvulae conniventes (stacked coin appearance) in jejunal loops

• Tubular featureless appearance of ileal loops

• Absence of gas in the colon

• Air-fluid levels

• String of beads sign caused by trapping of gas in valvulae conniventes along the walls of dilated fluid-filled loops

Causes of pneumobilia

• Gallstone ileus

• Biliary-enteric anastomosis

• Recent ERCP

• Emphysematous cholecystitis

• Incompetence of sphincter of Oddi: sphincterotomy

Causes of large bowel obstruction

(triad of colicky abdominal pain, constipation or obstipation (absolute constipation for stool and flatus) and abdominal distension). Continuous pain may indicate bowel ischaemia. An abrupt onset suggests an acute obstructive event, while a subacute history associated with altered bowel habit may indicate malignancy. Caecal tenderness implies impending perforation.

• Luminal; faecal impaction; foreign body

• Intramural: colorectal malignancy; diverticulitis with stricture; Crohn’s disease; sigmoid volvulus (dilated ahaustral closed large bowel loop extending into the right upper quadrant; coffee bean sign produced by central thicker wall caused by double thickness of opposed bowel loops, separating the loop into two compartments lined by thinner outer walls); caecal volvulus (dilated large bowel loop extending into left upper quadrant, with preserved haustral pattern, and associated small bowel dilatation); endometriosis

• Extrinsic: hernias; adhesions

• Intestinal pseudo-obstruction (Ogilvie’s syndrome) (acute massive colonic dilatation in the absence of mechanical obstruction; caecum diameter >10 cm is associated with a risk of perforation)

Radiological features of large bowel obstruction

• Dilated peripheral colonic loops (>6 cm, except in caecum, where >9 cm is abnormal dilatation)

• Collapsed distal colon

• Small bowel dilatation depends on the competence of the ileocaecal valve

• Incomplete haustral markings

Features suggesting strangulation obstruction with bowel ischaemia

• Constant pain

• Tender irreducible external hernia

• Signs of peritonism

• Reduced bowel sounds

• Fever; tachycardia

• Raised WCC and CRP

• Acidosis; raised lactate

Risk factors for sigmoid volvulus

• Elderly

• Chronic constipation; laxative abuse

• Chronic neurological and psychiatric disease: Parkinson’s disease; multiple sclerosis; chronic schizophrenia; Alzheimer’s dementia

• Megacolon; Chagas’ disease

Percutaneous endoscopic gastrostomy complications in emergency practice

• Peri-stomal wound infection: cellulitis (pain, redness, induration), discharge, fluctuant mass at the site; may progress to necrotising fasciitis, peritonitis, deep wound abscess

• Buried bumper syndrome (internal bumper buried within gastric mucosa): peri-stomal leakage/infection; immobile catheter; abdominal pain and flow resistance on attempted flushing

• Inadvertent removal: if the PEG tube has been in situ for more than 1 month, a mature tract may be assumed to be present

• Gastric outlet obstruction: intermittent vomiting, cramping abdominal pain; aspiration pneumonia

Dyspepsia

A group of symptoms indicative of the presence of upper gastro-intestinal tract disease

There are four categories:

• Ulcer-like: abdominal pain

• Reflux-like (gastro-oesophageal reflux): heartburn; regurgitation; retrosternal discomfort

• Dysmotility-like (delayed gastric emptying): early satiety; post-prandial fullness and bloating

• Non-specific or unspecified

Alarm symptoms in dyspepsia

(indicating the need for early endoscopy)

• Age >50 years with recent onset dyspepsia

• Anorexia

• Progressive unintentional weight loss

• Unexplained iron deficiency anaemia (except in pre-menopausal women)

• Gastrointestinal bleeding: overt or occult (positive stool occult blood)

• Progressive dysphagia or odynophagia

• Persistent or recurrent vomiting

• Previous gastric ulcer

• Previous gastric surgery

• Ulcerogenic medication: NSAID/aspirin/steroid therapy

• Epigastric mass

• Epigastric pain severe enough to hospitalise patient

• Strong history of familial gastrointestinal cancer

• Concomitant disease with possible gastrointestinal involvement

Risk factors for gastric cancer

• Alcohol abuse

• Smoking

• Helicobacter pylori infection

• Autoimmune gastritis (pernicious anaemia)

• Menetrier’s disease

• Previous partial gastrectomy (>20 years ago)

• Positive family history of gastric cancer

• Familial adenomatous polyposis

Causes of unintentional weight loss

• Chronic infection: tuberculosis; fungal; AIDS; infective endocarditis

• Malignancy: carcinoma; lymphoma; leukaemia

• Inadequate dietary intake: immobility; dementia; impaired consciousness; anorexia; anorexia nervosa

• Endocrine: thyrotoxicosis, diabetes mellitus, adrenocortical insufficiency

• Behavioural: depression, eating disorders, psychosis

• Social: isolation; financial difficulties

• Gastrointestinal:

  • Gastrointestinal obstruction: neoplasm; stricture; adhesions
  • Motility disorders: achalasia, gastroparesis
  • Pancreaticoduodenal: pancreatic cancer, chronic pancreatitis
  • Small intestinal malabsorption
  • Bacterial overgrowth

Lower gastrointestinal bleeding

Usually originates distal to the duodenojejunal flexure

Bright red blood, with or without clots, usually indicates bleeding low in the colon or rectum

Dark red or maroon blood usually indicates bleeding higher in the colon or the small bowel

Melaena usually indicates bleeding in the stomach

Causes of lower gastrointestinal bleeding

Small bowel:

• Diverticular disease: Meckel’s diverticulum; pseudo-diverticula; jejunal diverticula

• Intusussception

• Mesenteric infarction

• Aorto-enteric fistula: primary/ secondary

• Vascular lesions: angiodysplasia; telangiectasia; arteriovenous malformation

• Tumours: lymphoma; gastrointestinal stromal tumours; carcinoid; adenocarcinoma

• Ulceration: Crohn’s disease; Zollinger-Ellison syndrome; NSAIDs, potassium supplements; vasculitis

Large bowel:

• Colonic diverticular disease (diverticulosis)

• Angiodysplasia (vascular ectasias); arteriovenous malformations

• Colitis

  • Ulcerative proctocolitis
  • Chronic radiation proctocolitis
  • Ischaemic colitis
  • Crohn’s colitis (granulomatous)

• Carcinoma

• Hamartomatous and neoplastic polyps

• Endometriosis

• Aorto-colonic fistula

Ano-rectal

• Haemorrhoids; rectal/colonic varices

• Anal fissure

• Radiation proctitis

• Solitary rectal ulcer syndrome

Associated symptoms with acute lower gastrointestinal bleeding

Abdominal pain:

• Ischaemic bowel: ischaemic colitis

• Inflammatory bowel disease: Crohn’s disease; ulcerative colitis

• Ruptured abdominal aortic aneurysm

Painless bleeding:

• Diverticuli (diverticular disease)

• Angiodysplasia

• Polyps

• Haemorrhoids

Bloody diarrhoea:

• Inflammatory bowel disease

• Infection: infectious colitis (E coli O157: H7; Shigella; Salmonella; Campylobacter jejuni)

Rectal pain:

• Anal fissure

• Haemorrhoids

Constipation:

• Colorectal malignancy

• Haemorrhoids

Causes of upper gastrointestinal bleeding

(bleeding proximal to the ligament of Treitz at the duodeno-jejunal flexure).

Upper gastrointestinal bleeding can present with the vomiting of frank blood (haeamatemesis) or of coffee ground vomitus (dark coloured vomit containing altered blood), with or without melaena (passage of dark and tarry stools).

• Peptic ulcer disease: gastric; duodenal

• Drug-associated upper gastrointestinal tract erosive disease: aspirin, NSAIDs, steroids, bisphosphonates

• Oesophagitis

• Mallory-Weiss tear (haematemesis following repeated episodes of retching and vomiting, caused by longitudinal mucosal tear in distal oesophagus or gastric cardia; usually self limiting with spontaneous healing)

• Gastric/oesophageal varices (may have jaundice, ascites, hepatic encephalopathy, and stigmata of chronic liver disease-spider naevi, palmar erythema, splenomegaly)

• Stress ulceration

• Gastritis/ gastric erosions; haemorrhagic gastritis

• Tumours: gastric; oesophageal

• Cameron ulcers within hiatus hernia

• Swallowed blood from nasal bleeding

• Rare:

  • Aneurysms: aortic; splenic artery
  • Aorto-duodenal fistula: prior aortic surgery; abdominal aortic aneurysm
  • Aorto-oesophageal fistula (Chiari’s triad of mid-thoracic pain, sentinel upper gastrointestinal bleeding, and exsanguination after a symptom-free interval; associated with thoracic aortic aneurysm, foreign body ingestion, oesophageal malignancy, and prosthetic graft erosion)
  • Arterial malformations of stomach (Dieulafoy lesion-a large tortous superficial mucosal arteriole)
  • Pancreatic tumours; chronic pancreatitis; pancreatic pseudocysts; pancreatic pseudoaneurysms
  • Haemobilia: bleeding from gallbladder or biliary tree; abdominal trauma, biliary tract instrumentation, pancreatic pseudocyst
  • Hereditary haemorrhagic telangiectasia
  • Pseudoxanthoma elasticum
  • Angiodysplasia
  • Ehlers-Danlos syndrome
  • Haemostatic disorders

Pitfalls in the diagnosis of gastro-intestinal bleeding

Exogenous blood

• Epistaxis

• Uncooked meat

Black stools

• Iron preparations

• Grape juice; purple grapes

• Spinach

• Chocolate

Pseudo-blood

• Medications in red syrup

• Beets; tomato skin/juice

• Red diaper syndrome

• Peach skin; red cherries

• Cranberry juice

Clinical evaluation of upper gastrointestinal bleeding

• Haemodynamic status: vital signs and postural changes

• Signs of generalized vascular malformations/ disorders: petechiae; telangiectasia

• Signs of chronic liver disease (digital clubbing, leukonychia, palmar erythema, spider naevi, scratch marks, hepatosplenomegaly, ascites, peripheral oedema)

• Signs of portal hypertension: ascites

• Signs of hepatic encephalopathy

• Source of bleeding in pharynx or anterior nares

• History of dyspepsia, dysphagia or odynophagia

Risk stratification in acute upper gastrointestinal bleeding

• Age

• Presence of shock

• Co-morbidities

• Major stigmata of recent haemorrhage

• Cause of bleeding

Potential sources of obscure gastro-intestinal bleeding

• Vascular ectasias

• Small intestinal neoplastic lesions

• Hemosuccus pancreaticus: bleeding from peri-pancreatic blood vessels into a pancreatic duct

• Haemobilia: haemorrhage into a biliary duct (triad of right upper abdominal pain, jaundice and acute upper gastrointestinal bleeding)

• Aorto-enteric fistula

• Dieulafoy’s lesion (erosion of, and bleeding from, a gastric submucosal arteriole)

• Meckel’s diverticulum

• Extra-oesophageal varices: gastric; small intestinal; colonic

• Diverticula, especially small intestinal

• Cameron lesions (linear erosions or ulcers of gastric mucosal folds) within hiatus hernia, caused by diaphragmatic compression

Clinical presentations of colorectal cancer

Right sided lesions

• Occult blood loss, with insidious onset of unexplained iron deficiency anaemia

• Distal ileal obstruction

• Palpable right iliac fossa mass

• Fever of unknown origin

• Acute appendicitis

• Left-sided lesions

• Visible blood in stool

• Altered bowel habit

• Large bowel bbstruction

Clinical risk factors for colorectal cancer

• Genetic

• Polyposis syndromes: familial polyposis coli; Gardner’s syndrome; Turcot syndrome; Oldfield’s syndrome; Peutz-Jeghers syndrome

  • Hereditary non-polyposis syndromes: Lynch syndrome I; Lynch
  • syndrome II

• Pre-existing disease

• Inflammatory bowel disease: ulcerative colitis; Crohn’s disease

• Prior colorectal cancer

• Adenomatous polyps

• Pelvic irradiation

• Breast or genital tract cancer

• Schistosomiasis

• General

• Age of onset of symptoms >40 years

• Positive family history of colorectal cancer: 1st degree relative with colorectal cancer or adenomatous polyps diagnosed before the age of 60

Presentations of rectal cancer

• Persistent or recurrent rectal bleeding, especially with onset aged over 40 years

• Altered bowel habit

• Tenesmus

• Atypical presentations: “piles”; anal pain from anoderm involvement; secondary deposits: chest; liver

  • Local complications
  • Perforation: local abscess; generalised peritonitis
  • Intestinal obstruction
  • Abscess: sacral/perineal pain
  • Fistula: bladder (male); vagina (female)

Causes of pruritus ani

• Anorectal disease: inflammatory bowel disease (Crohn’s disease); haemorrhoids (external, internal); fistulae

• Infections: bacterial infections; Candida; pinworms (Enterobius vermicularis); viral infections (anal warts)

• Hygiene: inadequate or overzealous (soap, scent, lotion)

• Skin conditions: psoriasis, seborrhoeic dermatitis, contact dermatitis, lichen planus, lichen simplex, lichen sclerosus, Bowen’s disease

Causes of anal and rectal pain

• Thrombosed external haemorrhoid: acute severe pain; bluish purple tender swelling, covered with perianal skin and with minimal induration, at the anal verge

• Anal fissure: linear ulcer in epithelial lining of anal canal distal to the dentate line, usually in the posterior midline; pain and bright red bleeding during and after defaecation; with chronicity, sentinel tag at distal pole, hypertrophied anal papilla in the anal canal proximal to the fissure, and circular fibres of the internal anal sphinter visible in the base

• Ano-rectal abscess: perianal pain, worse on sitting and with defaecation and indurated swelling at the anal verge; fever and chills; associated with diabetes mellitus, Crohn’s disease and chronic corticosteroid therapy. Fluctuation is a late feature and is not required in order to make the diagnosis. Ischiorectal abscess presents with gluteal pain and induration. With supralevator or intersphincteric abscesses, no visible external manifestations may be present, and severe rectal pain may be accompanied by urinary symptoms (eg dysuria; inability to void, and urinary retention)

• Prolapsed strangulated or thrombosed internal haemorrhoid: rectal bleeding, pruritus

• Acute proctitis

• Rectal foreign body

• Anal cancer

• Proctalgia fugax

Causes of ascites

Normal peritoneum

• Portal hypertension

  • Parenchymal liver disease: cirrhosis; alcoholic hepatitis; fulminant hepatic failure; massive liver metastases
  • Hepatic congestion: congestive heart failure; constrictive pericarditis; veno-occlusive disease; Budd-Chiari syndrome; tricuspid regurgitation

• Hypoalbuminaemic states: nephrotic syndrome; severe malnutrition, protein-losing enteropathy

• Miscellaneous: chylous ascites (lymphatic leak), pancreatic ascites, biliary ascites, nephrogenic ascites, urine ascites, ovarian tumours; myxoedema

Diseased peritoneum

• Infections: bacterial peritonitis, tuberculous peritonitis, fungal peritonitis, HIV-associated peritonitis

• Malignancy: peritoneal carcinomatosis; hepatocelllular carcinoma; metastatic disease; primary mesothelioma

• Other: granulomatous peritonitis, vasculitis, Familial Mediterranean Fever, eosinophilic peritonitis (Mnemonic for causes of abdominal swelling: fat, fluid, flatus, faeces, foetus)

Causes of abnormal gas patterns on plain abdominal x-ray

Air inside the bowel (intra-luminal air):

• Ileus

• Obstruction

• Gas outlining mucosal lesion

Extra-luminal:

• Free peritoneal

• Retroperitoneal

• Loculated peritoneal, ie abscess

Air following known anatomical structures:

• Intramural air

• Biliary air

• Portal venous air

Causes of intestinal intramural gas

Linear pattern associated with ischaemia or infarction

• Mesenteric vascular disease

• Obstruction

• Toxic colon, eg colitis; necrotising enterocolitis

Linear gas without infarction

• Connective tissue disorders, eg scleroderma

• Caustic ingestion

• Iatrogenic, eg post-surgery catheterisation, stenting, endoscopic biopsy

• Immunosuppression

Cystic gas pattern

• Pneumatosis cystoids intestinalis

• Associated with chronic obstructive lung disease

Causes of pneumoperitoneum

• Perforated abdominal hollow viscus: duodenal ulcer; ischaemic bowel; bowel obstruction; inflammatory bowel disease; diverticulitis

• Mechanical perforation: trauma; colonoscopy; foreign body; iatrogenic

• Post-operative free intra-peritoneal gas: laparotomy; laparoscopy

• Peritoneal dialysis

• Vaginal aspiration: vaginal douching, vaginal insufflation with air during sexual activity (coitus; oral sex); waterskiing

• Mechanical ventilation

• Pneumatosis cystoides intestinalis

Features of pneumoperitoneum on supine x-rays

• Gas in the right upper quadrant, which may be peri-hepatic, sub-hepatic, or in the hepato-renal space

• Visualisation of the falciform and medial umbilical ligaments

• Double wall (Rigler’s) sign

Causes of pseudo-peritoneum

• Sub-diaphragmatic extraperitoneal fat

• Multicontoured diaphragm

• Interposition of transverse colon or small bowel between liver and diaphragm (Chilaiditi syndrome)

• Basilar horizontal plate atelectasis

• Interposition of omental fat between liver and diaphragm

• Diaphragmatic hernia

• Large diverticulum arising in subdiaphragmatic oesophagus, stomach, or duodenum

• Sub-pleural air

Causes of nausea and vomiting

Upper gastrointestinal disorder

• Reflux oesophagitis

• Gastric outlet obstruction

• Small bowel obstruction

• Acute gastritis (alcoholic)/gastroenteritis (viral, bacterial, parasitic)

• Acute cholecystitis

• Acute pancreatitis

• Acute hepatitis

• Diabetic gastroparesis

Therapeutic drug use:

• Opiates

• Cardiac glycosides: digoxin

• Cancer chemotherapy

• Antibiotics

Drug toxicity: paracetamol; digoxin; theophylline

Drug abuse: narcotics; alcohol; narcotic withdrawal

CNS:

• Migraine

• Labyrinthine disease: acute labyrinthitis; motion sickness

• Raised intracranial pressure

• Head injury

Psychological (self-induced)-eating disorders:

• Anorexia nervosa

• Bulimia

• Psychogenic vomiting

Metabolic/endocrine

• Hyperparathyroidism

• Chronic kidney disease

• Acute adrenocortical insufficiency

• Diabetic ketoacidosis

• Acute liver failure

Pregnancy:

• Physiological

• Hyperemesis gravidarum

Genitourinary: pyelonephritis

Miscellaneous; electrolyte disorder; glaucoma

Causes of small intestinal fluid levels on plain abdominal xray:

• Large intestinal obstruction

• Small intestinal obstruction

• Paralytic ileus

• Cleansing enemas

• Gastroenteritis

• Hypokalaemia

• Uraemia

• Jejunal diverticulosis

• Mesenteric thrombosis

• Normal (always <2.5 cm long)

• Peritoneal metastases

Causes of hiccups

• Gastrointestinal: gastric distension; gastroesophageal reflux; hepatitis; cholecystitis; cholelithiasis; bowel obstruction; pancreatitis

• Diaphragmatic irritation: hiatal hernia; abdominal mass; peritonitis

• CNS: stroke; infection; ventriculo-peritoneal shunt

• Chest: pneumonia

• Metabolic: uraemia; hyponatraemia; hypocalcaemia

• Toxic/ drug induced: alcohol; chemotherapeutic agents

• Psychogenic: stress; grief

• Idiopathic

Causes of jaundice

Pre-hepatic (increased production of bilirubin) (unconjugated hyperbilirubinaemia)

• Genetic diseases: sickle cell disease; thalassemia (ineffective erythropoeisis); glucose 6 phosphate dehydrogenase deficiency

• Increased breakdown of red blood cells (increased reticulocyte count): haemolytic anaemias (eg, hereditary spherocytosis) (unconjugated hyperbilirubinaemia, anaemia with reticulocytosis)

Intra-hepatic

Hepatocellular (reduced hepatic uptake of, or conjugation of, bilurubin)

• Viral hepatitis (hepatitis A, B, C, D, E)

• Autoimmune hepatitis

• Alcoholic liver disease: acute alcoholic hepatitis; cirrhosis

• Leptospirosis

• Disorders of bilirubin metabolism (impaired hepatocellular conjugation of bilirubin): Gilbert’s syndrome; Crigler-Najjar syndrome; Dubin-Johnson syndrome; Rotor syndrome

Cholestasis

• Familial and congenital: benign recurrent intrahepatic cholestasis, Caroli’s disease

• Viral hepatitis

• Infiltration: granuloma; cancer

• Hepatotoxic drugs: anabolic steroids; oral contraceptive

• Primary biliary cirrhosis

• Cholangiocarcinoma

• Primary sclerosing cholangitis; autoimmune cholangiopathy

• Vanishing bile duct syndrome (complication of drug-induced liver injury leading to progressive destruction of the intra-hepatic bile ducts and chronic cholestasis)

• Sepsis

Post-hepatic cholestasis (extrahepatic biliary obstruction).

Inside bile duct (intra-ductal)

• Gallstones in common bile duct

• Parasites

Inside wall:

• Biliary tract tumours: gallbladder cancer; cholangiocarcinoma

• Common bile duct stricture

• AIDS cholangiopathy

Outside duct wall:

• Cancer in head of pancreas

• Pancreatitis (acute; chronic)

• Tumour/lymph nodes in porta hepatis: lymphoma, cholangiocarcinoma, metastatic carcinoma

• Pancreatic pseudocyst

Causes of biliary obstruction

Intrahepatic

• Hepatitis

• Cirrhosis: post-hepatitic; primary biliary cirrhosis

• Drugs: anabolic steroids; chlorpromazine

Extrahepatic

• Intra-ductal: neoplasm; stone; parasite (Ascaris lumbricoides); biliary stricture; primary sclerosing cholangitis; AIDS-related cholangiopathy; biliary tuberculosis

• Extra-ductal: neoplasm (cholangiocarcinoma; metastases; cance of head of pancreas); pancreatitis; parasites (Ascaris lumbricoides; liver flukes)

Risk factors for jaundice

• Liver disease

• Previous episodes of jaundice

• Blood transfusion

• Intravenous drug use

• Alcohol history

• Sexual history

• Travel history

• Drug history, including over-the-counter, recreational and herbal

• Contacts: environmental and food exposure

Causes of jaundice with fever

Pre-hepatic jaundice

• Haemolysis: severe malaria; Mycoplasma pneumoniae; sickle cell crisis

Hepatic jaundice

• Viral hepatitis

• Enteric fever: Salmonella hepatitis

• Viral haemorrhagic fever

• Liver abscess (amoebic; pyogenic)

• Rickettsial infections

• Infectious mononucleosis

• Leptospirosis (biphasic illness of initial flu-like illness with fever, anorexia, nausea and vomiting, headache and myalgia, followed by haemorrhages, jaundice, hepatorenal syndrome (acute kidney injury)) (occupational risk factors include sewage workers, veterinarians, abattoir workers, rodent control workers, and famers; recreational risk factors include activities in freshwater such as swimming, sailing, water skiing and wind surfing)

• Drug induced hepatitis: amoxicillin with clavulanic acid, NSAIDs, carbamazepine

Post-hepatic jaundice

• Biliary tract infection: acute cholecystitis; choledocholithiasis with ascending cholangitis (Charcot’s triad of intermittent fever with chills, right upper quadrant abdominal pain and jaundice); biliary ascariasis

Bedside ultrasound evaluation of the biliary tract

Gallstones

• Echogenic objects within the echo-free gallbladder lumen

• Distal acoustic shadowing

• Mobile, and move with changes in position of the patient: demonstrate gravitational dependency, seeking the most dependent portion of the gallbladder

• The lumen of the gallbladder may contain lithogenic bile, known as sludge, which has low-level echogenicity (it appears less white than stones), tends to layer out in the dependent portion of the gallbladder with a flat fluid: fluid interface, and fails to shadow.

Acute cholecystitis

• Symmetrical thickening of the entire gall bladder wall >3 mm

• Dilated gall bladder: >10 cm in length; >4 cm in width

• Echo-poor halo around the gallbladder-due to intramural oedema-alternating echogenic and hypo-echoic layers within the wall

• Gallstones

• Impacted stone in neck of gallbladder

• Gas in gallbladder wall

• The sonographic Murphy sign represents local tenderness and inspiratory arrest over the sonographically visualised gallbladder

• Increased flow with colour Doppler

• Peri-cholecystic fluid: focal anechoic collection adjacent to the gallbladder, especially in the region of the fundus; collection >1 cm indicates gallbladder perforation

Acute Liver Failure

Features

• Jaundice

• Ascites

• Peripheral oedema

• Encephalopathy (confusion, flapping tremor, constructional apraxia); cerebral oedema

• Coagulopathy

• Upper gastrointestinal bleeding

• Acute kidney injury

• Sepsis

• Previously normal liver function

Causes

• Hepatotoxicity: dose dependent: paracetamol overdose, methyldioxymethamphetamine; idiosyncratic drug reactions (isoniazid; NSAIDs, antiepileptic drugs, antibi​otics-rifampicin)

• Acute viral hepatitis: hepatitis A, B, C, D, E; cytomegalovirus, adenovirus, haemorrhagic fever viruses, herpes simplex virus, Epstein-Barr virus, paramyxovirus

• Autoimmune hepatitis

• Acute steatosis syndromes (extensive hepatocyte infiltration with fat microdroplets and minimal hepatocellular necrosis): acute fatty liver of pregnancy; Reye’s syndrome; acute alcoholic hepatitis

• Toxins: Amanita phalloides (mushroom ingestion), Bacillus cereus, yellow phosphorus, organic solvents (hydrocarbons, eg carbon tetrachloride)

• Vascular: ischaemic hepatitis (shock liver); hepatic vein thrombosis (Budd-Chiari syndrome); hepatic veno-occlusive disease; portal vein thrombosis; hepatic artery thrombosis; congestive heart failure; right heart failure

• Metabolic: α1-antitrypsin deficiency; hereditary fructose intolerance; galactosaemia; LCAT (lecithin-cholesterol acyltransferase) deficiency; Reye’s syndrome; hepatolenticular degeneration; tyrosinaemia

• Malignancy: primary liver tumours (hepatocellular carcinoma, cholangiocarcinoma); secondary tumours (extensive hepatic metastases from adenocarcinoma, melanoma, lymphoma); leukaemia

• Miscellaneous: adult-onset Still’s disease; heatstroke

Laboratory findings

• Hepatic injury: elevated transaminases (ALT, AST, GGT)

• Hepatic dysfunction: coagulopathy not correctable with vitamin K; hypoglycaemia; hypoalbuminaemia; increasing bilirubin; hyperammonaemia; high lactate

Causes of coagulopathy in liver disease

• Cholestasis causing vitamin K malabsorption, with impaired synthesis of vitamin K-dependent coagulation factors II, VII, IX and X)

• Hepatocellular disease leading to failure of γ carboxylation of coagulation factors and reduced synthesis of all coagulation factors except Factor VIII and von Willebrand factor

Factors precipitating hepatic encephalopathy

• Gastrointestinal bleeding

• Sepsis; spontaneous bacterial peritonitis

• Azotemia and hypovolaemia (diuretic-induced)

• Hypokalaemia; alkalosis

• CNS depressant drugs: sedatives (benzodiazepines); opiates; tricyclic antidepressant drugs

• Hepatocellular injury

• Constipation

• High protein diet

• Hypoglycaemia

• Post-portosystemic shunt placement

Causes of hepatomegaly

• Infection: viral: hepatitis (acute; chronic), infectious mononucleosis; parasitic: malaria; abscess: pyogenic, amoebic

• Vascular congestion: supra-hepatic: congestive heart failure, right ventricular failure, constrictive pericarditis, Budd-Chiari syndrome; intra-hepatic: veno-occlusive disease

• Infiltration: neoplasm (primary: hepatocellular carcinoma; metastases); haematological malignancy: lymphoma, leukaemia; granuloma: sarcoidosis, tuberculosis; extramedullary haematopoeisis: haemolytic anaemias, haemoglobinopathies –thalassaemia, sickle cell disease)

• Storage disorders: fat: non-alcoholic hepatic steatosis, diabetes mellitus, obesity, mucopolysaacharidoses; lipid-lipidoses (Niemann-Pick; Gaucher); metals: copper (hepatolenticular degeneration), iron (haemochromatosis); abnormal protein: alpha1-antitrypsin; glycogen: glycogen storage disease

• Biliary tract obstruction: extra-hepatic biliary obstruction (cholelithiasis; tumour)

Causes of splenomegaly

• Infection: viral: infectious mononucleosis, cytomegalovirus, HIV; bacterial: tuberculosis, infective endocarditis, brucellosis, syphilis, typhoid; fungal: histoplasmosis; parasitic: malaria, visceral leishmaniasis, hydatid disease, schistosomiasis; rickettsial: typhus

• Congestive splenomegaly due to portal hypertension: cirrhosis (alcoholic liver disease; primary biliary cirrhosis; hepatitis B/C); portal vein thrombosis; splenic vein thrombosis

• Haematological causes: haemolytic anaemias ; haemoglobinopathies (early sickle cell disease, thalassaemia); haemoglobinopathies; myeloproliferative disorders: chronic leukaemia, acute leukaemia, polycythaemia vera, lymphoma, essential thrombocytosis; extramedullary haematopoiesis: myelofibrosis (agnogenic myeloid metaplasia)

• Space occupying lesions: cyst; haemangioma

• Trauma: subcapsular haematoma

The 3 Ms of massive splenomegaly are chronic myeloid leukaemia, myelofibrosis, and malaria

Significant findings with blunt abdominal trauma

• Hypovolaemic shock

• Evidence of intraperitoneal penetration: signs of peritonism (guarding, rebound tenderness); free intraperitoneal air; omental evisceration; implement in situ

• Gastrointestinal bleeding

• Seat belt marks

• Steering wheel contusion

• Bicycle handlebar marks on the upper abdomen

• Macroscopic haematuria

• Flank (Grey Turner) or peri-umbilical (Cullen) ecchymosis

• Abdominal bruit

Confounding factors in the evaluation of abdominal trauma

• Head injury with altered level of consciousness

• Alcohol/drug intoxication

• Spinal cord injury

• Distracting injury

Potential involvement with blunt abdominal trauma

• Solid viscus: liver, spleen, kidneys, pancreas

• Hollow viscus: small intestine; large intestine; stomach; oesophagus; urinary bladder

• Vascular injuries: aorta; inferior vena cava

• Bones: pelvis; lumbar spine

• Diaphragm

Features of seat belt syndrome

• Abdominal wall contusion

• Iliac or pubic fractures

• Lumbar spine fractures: wedge compression fracture; Chance fracture

• Intra-abdominal injuries: small bowel perforation; mesenteric tears; bladder rupture