Gastroenterology 2

Diagnostic methods for

gastrointestinal diseases
Laboratory investigations
 ESR: increased: inflammation, tumors (but
can be normal)
 Blood count
– leukocytes: : inflammation
– eosinophilia: helminthiasis, allergy
– anemia (Hb, HCT): GI bleeding (manifest or
occult)
 Se Iron : bleeding, malabsorption, chr.infection
Laboratory investigations
 Liver tests:
– AST(GOT), ALT(GPT): cell damage
– ALP, GGT, bilirubin: cholestasis
– prothrombin time , se albumin  : liver failure
 Pancreas: amylase, lipase, functional tests
 Fecal occult blood test (FOBT)
 Stool cultures for bacteria and parazites
 Urine: jaundice, uroinfection, kidney stone
 Duodenal aspiration
Abdominal ultrasound
 features

 specific US methods
– Doppler-ultrasound - for vascular lesions
– US-guided biopsy
– EUS- endoscopic ultrasound - endosonography
Abdominal ultrasound
 Liver
– echogenity, masses, cysts, bile ducts, veins
 Biliary tract
– gallstones (hyperechoic lesion with acoustic
shadow), sludge, CBD stones, cholecystitis
 Pancreas
– acute pancreatitis, chr.pancreatitis, pseudocysts,
tumors
 Others
– ascites, organomegalies, lymph nodes,
appendicitis, intraabdominal masses (tumor,
abscess, cyst, inflammatory mass), kidneys
Radiology
 Plain abdominal X-ray
 free air (upright position)
 gas/fluid levels within dilated loops
 calcifications
 Upper GI barium radiography
(single or double contrast studies)
– esophagus (first examination in dysphagia)
 contour, peristalsis, folds
 motility disorders, stenoses
 Radiology
 Upper GI barium radiography
– stomach and duodenum
 peristalsis, emptying, shape, folds, retrogastric space
 perforation: with water-soluble contrast agent
 in case of GI hemorrhage: endoscopy
 Barium study of the small bowel
 small bowel follow through study
 enteroclysis
 stenoses, polyps, mucosal alterations, ileitis terminalis
Radiology
 Barium enema (double-contrast)
(synonims: irrigoscopy, colonography)

 mostly in cases of stenosis on endoscopy

Radiology - angiography
 diagnosis of vascular diseases, obscure GI
bleedings
 therapeutic angiography is evolving
(chemoembolisation of tumors, occluding
bleeding vessels, dilation of vessels)
Computer tomography
 features

 specific CT methods
– spiral/helical CT
– contrast agents (orally administered, iv.)
– CT-guided biopsy
– virtual colonoscopy
Computer tomography
 Liver
– masses (benign, malignant [primary or
metastatic neoplasms], hemangiomas, cysts,
abscesses) , cirrhosis, ascites and other signs
of portal hypertension, lymph nodes
 Biliary tract
– dilated bile ducts, imaging of CBD, distal
bile duct stones, CBD neoplasms
Computer tomography
 Pancreas - (the most useful method)
– neoplasms: diagnosis, staging
– acute pancreatitis: extent of necrosis,
peripancreatic fluid collections, guided
biopsies
– chr. pancreatitis: pseudocysts, calcifications
 Miscellaneous
– staging of gastrointestinal malignancies, intra-
abdominal masses (abscess, inflammatory,
tumors), invasion of adjacent structures
Magnetic resonance imaging
 generally not superior to CT in abdominal
diseases
 sensitive
 very expensive
 special methods
– MR angiography
– MRCP - magnetic resonance cholangio-
pancreatography
Endoscopy
 features

 diagnostic endoscopy
– provides histological sampling (biopsy,
brush cytology)
 therapeutic endoscopy
 Upper GI endoscopy
Esophagogastroduodenoscopy (EGD)
 Diagnostic
 GI bleeding
 refractory vomiting
 dysphagia, odynophagia
 gastroesophageal reflux
 ulcers
 suspicion of neoplasm (weight loss, etc.)
 surveillance of healing lesions
 surveillance of polyps, tumors
Upper GI endoscopy
 Therapeutic
 treatment of variceal and nonvariceal GI
bleeding
– injection technics, hemoclip, ligation,
thermal technics (elelctrocoagulation, heat probe,
laser, argon plasma)
 removal of polyps, early neoplasms
 dilation of strictures
 placement of feeding gastrostomy tube
 removal of foreign bodies
Capsule endoscopy
Lower GI endoscopy
Colonoscopy, rectosigmoidoscopy, rectoscopy
 Diagnostic
– Bleedings (occult or hematochezia, iron
deficiency)
– Chronic diarrhea
– Suspicion of cancer
– Suspicion of inflammatory bowel disease
– Screening for cancer (altered bowel habits,
risk groups for colon cancer)
Lower GI endoscopy
Colonoscopy, rectosigmoidoscopy, rectoscopy

 Therapeutic
 Removal of polyps, early cancers
 Dilation of stenoses
 Decompression
Endoscopic retrograde cholangio-
pancreatography - ERCP
 Diagnostic
 suspicion of choledocholithiasis
 unexplained jaundice and cholestasis
 acute gallstone pancreatitis
 some cases of chr. pancreatitis

 Therapeutic
 endoscopic sphincterotomy - EST
 endoscopic biliary/pancreatic drainage
 endoscopic biliary/pancreatic stenting
 dilation of strictures
 endoscopic lithotripsy
Miscellaneous diagnostic methods
 Biopsies (US/CT-guided)- liver, pancreas, masses
 Punctions - ascites, cysts
– Percutaneous transhepatic cholangiography (PTC) or
drainage (PTD)
 Laparoscopy
 Helicobacter pylori diagnostics
– stains, rapid urease-test, urease breath test (UBT)
 24h pH monitoring
 Manometry (esophageal, rectal, Oddi-sphincter,
bowel)
Common abdominal
syndromes
Gastroesophageal reflux disease -
GERD
 History:
– Esophageal: heartburn, chest pain, regurgitation, acidic taste
in mouth, dysphagia, odynophagia, Extraesophageal:
chr.cough, asthma, noncardiac chest pain
 Characteristics: increase in laying position

night symptoms
resolve after antacids
 Physical findings:
 Diagnosis: history, endoscopy, pH-
monitoring, barium swallow
 Esophageal cancer
 History: dysphagia, odynophagia, pain, vomiting,
weight loss
 Characteristics: older males, alcoholics, smokers

progressive dysphagia (solidsofterliquid)

vomiting just after meals
 Physical finding: general tumor signs
 Diagnosis: barium swallow, endoscopy
Peptic ulcer (duodenal, gastric)
 History: epigastric pain
 Characteristics:
– radiates to the back
– duodenal: younger people, hyperacid symptoms,
relapsing disease, more symptoms in spring and fall, pain
resolves after meals and recur after 2 hours, night pain,
resolve using antacids
– gastric: older people, pain just after meals, weight loss
– smokers
– NSAID (aspirin) use
Peptic ulcer (duodenal, gastric)
 Physical finding: epigastric/RUQ tenderness
 Diagnosis: endoscopy
 Peptic ulcer - complications
 Bleeding: melena, hematemesis,

(rarely: hematochezia)
rectal digital examination
 Perforation: acute onset
very sharp pain (knife-like)
liver/splenic dullnes: absent
peritoneal signs: defence (guarding),
rebound tenderness, no bowel sounds
Dg: abdominal plain film
study with water-soluble contrast agent
Peptic ulcer - complications
 Obstruction a. reversible

b. irreversible (scar)
History: vomiting of undigested food
fullness, pain
Physical signs: succussion splash
tenderness
Diagnosis: gastric emptying study (barium)
endoscopy
 Gastric cancer
 History: epigastric pain, fullness, vomiting,
weight loss
 Characteristics: older people,
pain arise at meals
dull, progressive pain
 Physical findings:epigastric pain, epigastric mass
Virchow’s lymph node
general tumor signs
occult bleeding
 Diagnosis: endoscopy, US
Acute appendicitis
 History: first periumbilical, later ileocecal pain
nausea
subfebrility
 Characteristics: invariable
first colicky, than steady pain
 Physical findings: ileocecal tenderness
(McBurney’s point)
ileocecal guarding
rebound tenderness
obturator sign: pain rotating the right hip
psoas sign: pain raising against resistance the
straightened right leg
 Diagnosis: physical examination, US, laboratory
Intestinal obstruction (ileus)
1. Mechanical
 History: altered bowel habits, constipation,
fullness, meteorism, cramping pain, vomiting
(bile, fecal material)
 Characteristics: variable or progressive
 Physical finding: meteorism
increased bowel sound
splash
signs of underlying disease
 Diagnosis: plain abdominal x-ray, CT
searching for the cause
Intestinal obstruction (ileus)
2. Paralytic
 History: signs of the underlying disease,
constipation, fullness, meteorism, cramping
pain, vomiting
 Physical finding: meteorism
absent bowel sound
splash
signs of the underlying
disease
 Diagnosis: plain abdominal x-ray

searching for the cause

Colorectal cancer
 History: altered bowel habits
bleeding (occult or manifest)
late: signs of obstruction
cramping pain
general tumor signs
positive family history
 Physical finding:rectal digital examination
late: mass, ileus
 Diagnosis: endoscopy, US, CT
Acute hepatitis
 History: asymptomatic
after flu-like symptoms jaundice
anorexia, dyspepsia
RUQ pain
 Physical finding: jaundice
enlarged liver: smooth, soft, round, tender
 Diagnosis: liver tests, virus tests
Chronic hepatitis
 History: symptoms: not characteristic
anorexia, dyspepsia
later: symptoms of cirrhosis
 Physical finding: enlarged liver (can be normal)
 Diagnosis: US, liver biopsy, serology
Liver cirrhosis
 History: alcohol consumption, chr. hepatitis
(HBV, HCV, HDV, HGV, autoimmune),
anorexia, dyspepsia, nausea
ascites, edemas, portal encephalopathy
jaundice, bleeding
 Physical findings:
first: enlarged liver micronodular: alcoholic
macronodular: chr. virus
or autoimmune hepatitis- postnecrotic cirrhosis
end stage: small liver
Liver cirrhosis
 Physical findings:
skin: palmar and plantar erythema
spider naevi
icterus (scratching)
gynecomasty
testicular atrophy
signs of portal hypertension:
ascites (transsudate)
caput Medusae
splenomegaly
edema
 Diagnosis: US, liver biopsy, laboratory
 Biliary colic
 History:pain after fatty meals
nausea, vomiting (often bile)
fullness, meteorism
 Characteristics: RUQ-pain, radiates to the back
(scapula, right shoulder)
mostly females
 Physical finding: RUQ tenderness
 Diagnosis: US
Acute cholecystitis
 History: like in biliary colic + fever
 Physical finding: Murphy’s sign
 Diagnosis: US, laboratory: signs of
inflammation

Choledocholithiasis
 History: like in biliary colic + obstr. jaundice
 Diagnosis: US, ERCP, CT
Acute pancreatitis
 History: gallstone disease, fatty meal, alcohol
epigastric pain
fullness, nausea, vomitus
fever
jaundice
hypotony, shock
 Characteristics: band-like, cramping pain

radiates to the back

Acute pancreatitis
 Physical findings:
epigastric tenderness/guarding
peritoneal signs
signs of paralytic ileus (meteorism, no bowel

sounds)
skin signs: Cullen’s sign-periumbilical
ecchymoses
Grey-Turner’s sign- lumbar
ecchymoses
 Diagnosis: pancreatic enzimes, US, CT
Chronic pancreatitis
 History: cramping pain
anorexia, dyspepsia, nausea, vomitus
gallstone or alcohol consumption
weight loss
steatorrhea
 Characteristics: pain in the back
increases after meals
 Physical finding: epigastric tenderness
epigastric mass (pseudocyst)
sometimes jaundice
 Diagnosis: plain abd. X-ray, US, CT, ERCP