Gastrointestinal Emergencies

Tony C. K. Tham, John S. A. Collins, Roy M. Soetikno, Tony C. K. Tham, John S. A. Collins, Roy M. Soetikno

• Publisher: Wiley-Blackwell
• Year: 2016
• ISBN:
  9781118638385
• Edition: 3
• Topic: Medicine
• Subtopic: Gastroenterology & Hepatology

Gastrointestinal Emergencies 3E provides practical, up-to-date guidance for gastroenterologists, endoscopists, surgeons, emergency and acute physicians, medical students and trainees managing patients presenting with GI complications and/or emergencies.

Combining a symptom section, a specific conditions section and a section that examines complications (and solutions) of GI procedures, focus throughout is on clear, specific how-to guidance, for use before a procedure or immediately after emergency stabilization. An evidence-based approach to presentation, diagnosis and investigation is utilized throughout.

New to this third edition are severalbrand new chapters covering various complications of procedures and specific conditions not previously featured, as well as a thorough look at the many diagnostic and therapeutic advances in recentyears. In addition, every chapter from the current edition has undergone wholesale revision to ensure it is updated with the very latest in management guidelines and clinical practice. Once again, full range of emergencies encountered in daily clinical practice will be examined, such as acute pancreatitis, esophageal perforation, capsule endoscopy complications, acute appendicitis, and the difficulties after gastrointestinal procedures. International guidelines from the world's key gastroenterology societies will be included in relevant chapters.

Gastrointestinal Emergencies 3E is the definitive reference guide for the management of gastrointestinal emergencies and endoscopic complications, and the perfect accompaniment for the modern-day gastroenterologist, surgeon, emergency and acute physicians.

Every Emergency Department, GI/endoscopy unit, medical/surgical admission unit should keep a copy close at hand for quick reference.

SECTION 1
Approach to specific presentations

CHAPTER 1
Approach to dysphagia

John S. A. Collins

Northern Ireland Medical and Dental Training Agency, Royal Victoria Hospital, Belfast, UK

Definitions

Dysphagia refers to a subjective sensation of the obstruction of swallowed solids or liquids from mouth to stomach. Patients most frequently complain that food “sticks” in the retrosternal area or simply will “not go down.” Patients may complain of a feeling of choking and chest discomfort. In some cases food material is rapidly regurgitated to relieve symptoms.

Dysphagia can be divided into two types:

• oropharyngeal dysphagia, where there is an inability to initiate the swallowing process and may involve disorders of striated muscle. There may be a sensation of solids or liquids left in the pharynx.
• esophageal dysphagia, which involves disorders of the smooth muscle of the esophagus and results in symptoms within seconds of the Initiation of swallowing.

Odynophagia is the sensation of pain on swallowing which is usually felt in the chest or throat. Globus is the sensation of a lump, fullness or tightness in the throat.

Differential diagnosis

The causes of the above types of dysphagia are shown in Tables 1.1 and 1.2.

Table 1.1 Etiology of oropharyngeal dysphagia.

Neurological disorders Cerebrovascular disease Amyotrophic lateral sclerosis Parkinson’s disease Multiple sclerosis Bulbar poliomyelitis Wilson’s disease Cranial nerve injury Brainstem tumors Striated muscle disorders Polymyositis Dermatomyositis Muscular dystrophies Myasthenia gravis Structural lesions Inflammatory – pharyngitis, tonsillar abscess Head and neck tumors Congenital webs Plummer–Vinson syndrome Cervical osteophytes Surgical procedures to the oropharynx Pharyngeal pouch (Zenker diverticulum) Cricopharyngeal bar Metabolic disorders Hypothyroidism Hyperthyroidism Steroid myopathy

Table 1.2 Etiology of esophageal dyphagia.

Neuromuscular/dysmotility disorders Achalasia CRST syndrome Diffuse esophageal spasm Nutcracker esophagus Hypertensive lower esophageal shincter Nonspecific esophageal dysmotility Chaga disease Mixed connective tissue disease Mechanical strictures – intrinsic Peptic related to GERD Carcinoma Esophageal webs Esophageal diverticula Lower esophageal ring (Schatzki) Benign tumors Foreign bodies Acute esophageal mucosal infections Pemphigus/pemphigoid Crohn’s disease Mechanical lesions – extrinsic Bronchial carcinoma Mediastinal nodes Vascular compression Mediastinal tumors Cervical osteoarthritis/spondylosis

History and examination

Acute dysphagia is a relatively uncommon, but dramatic, presenting symptom and constitutes a gastrointestinal emergency. The patient will complain of difficulty initiating swallowing or state that food is readily swallowed but results in the rapid onset of chest discomfort or pain, which is only relieved by passage or regurgitation of the swallowed food bolus. The latter sensation can result after swallowing a mouthful of liquid. In the acute case it is important to ask the patient about the presence of other neurological symptoms.

If oropharyngeal dysphagia is suspected, the following points are important:

• The patient may complain of nasal regurgitation of liquid, coughing or choking during swallowing or a change in voice character which may indicate nasal speech due to palatal weakness.
• Patients may desc...