Gastroenterology and Hepatology

Stephen Inns, Anton Emmanuel

• Publisher: Wiley-Blackwell
• Year: 2016
• ISBN:
  9781118727041
• Edition: 2
• Topic: Medicine
• Subtopic: Gastroenterology & Hepatology

Gastroenterology and Hepatology Lecture Notes is a comprehensive yet easy-to-read overview of luminal gastroenterology and hepatology. Covering the epidemiology, causes, clinical features, investigation, treatment and prognosis of all the main gut and liver conditions, it is ideal for both exam preparation and fact finding. Key features include: •A full range of new illustrations, including clinical photographs and scans, that clearly demonstrate signs and symptoms
•Sections on anatomy, physiology, pharmacology, and epidemiology – written to enhance understanding of clinical features
•Essential information highlighted throughout the text
•Case-based self-assessment for each chapter helps retention of knowledge and puts it in its clinical context
•A new section of "best answer" MCQs
•New chapters on inflammatory bowel disease and different diagnosis of the upper GI tract
• Includes a companion website at www.lecturenoteseries.com/gastroenterology featuring 16 in-depth case studies Whether learning the basics of the gastrointestinal system, starting a general medical or gastroenterological placement, or looking for a quick-reference overview to revise key concepts,
Gastroenterology and Hepatology Lecture Notes is an ideal resource for medical students, MRCP or FRACP candidates, and junior doctors.

Part I
Clinical Basics

1
Approach to the patient with abdominal pain

In gastroenterological practice, patients commonly present complaining of abdominal pain. The clinician’s role is to undertake a full history and examination, in order to discern the most likely diagnosis and to plan safe and cost-effective investigation. This chapter describes an approach to this process. The underlying diagnoses and pathological mechanisms encountered in chronic pain are often quite different from those seen in acute pain, and for this reason each is considered in turn here.

Chronic abdominal pain

Anatomy and physiology of abdominal pain

Pain within the abdomen can be produced in two main ways: irritation of the parietal peritoneum or disturbance of the function and/or structure of the viscera (Box 1.1). The latter is mediated by autonomic innervation to the organs, which respond primarily to distension and muscular contraction. The resulting pain is dull and vague. In contrast, chemical, infectious or other irritation of the parietal peritoneum results in a more localised, usually sharp or burning pain. The location of the pain correlates more closely with the location of the pathology and may give important clues as to the diagnosis. However, once peritonitis develops, the pain becomes generalised and the abdomen typically becomes rigid (guarding).

Referred pain occurs due to the convergence of visceral afferent and somatic afferent neurons in the spinal cord. Examples include right scapula pain related to gallbladder pain and left shoulder region pain from a ruptured spleen or pancreatitis.

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Box 1.1 Character of visceral versus somatic pain

Visceral

• Originates from internal organs and visceral peritoneum
• Results from stretching, inflammation or ischaemia
• Described as dull, crampy, burning or gnawing
• Poorly localised

Somatic

• Originates from the abdominal wall or parietal peritoneum
• Sharper and more localised

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Clinical features

History taking

Initially the approach to the patient should use open-ended questions aimed at eliciting a full description of the pain and its associated features. Useful questions or enquiries include:

• ‘Can you describe your pain for me in more detail?’
• ‘Please tell me everything you can about the pain you have and anything you think might be associated with it.’
• ‘Please tell me more about the pain you experience and how it affects you.’

Only following a full description of the pain by the patient should the history taker ask closed questions designed to complete the picture.

In taking the history it is essential to elucidate the presence of warning or ‘alarm’ features (Box 1.2). These are indicators that increase the likelihood that an organic condition underlies the pain. The alarm features guide further investigation.

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Box 1.2 Alarm features precluding a diagnosis of irritable bowel syndrome (IBS)

History

• Weight loss
• Older age
• Nocturnal wakening
• Family history of cancer or IBD

Examination

• Abnormal examination
• Fever

Investigations

• Positive faecal occult blood
• Anaemia
• Leucocytosis
• Elevated ESR or CRP
• Abnormal biochemistry

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Historical features that it is important to elicit include those in the following sections.

Onset

• Gradual or sudden? Pain of acute onset may result from an acute vascular event, obstruction of a visc...