Gastrointestinal and Hepatic System



Gastrointestinal and Hepatic System





4-A. Nausea and Vomiting1


Central Nervous System Disorders

Increased intracranial pressure



  • Head trauma


  • Central nervous system neoplasms


  • Meningitis, encephalitis


  • Hydrocephalus


  • Pseudotumor cerebri


  • Subarachnoid hemorrhage


  • Epidural/subdural hematoma


  • Reye syndrome

Vestibular or middle ear disease



  • Motion sickness


  • Benign positional paroxysmal vertigo


  • Ménière disease


  • Acoustic neuroma


  • Labyrinthitis


  • Ear infections

Eye disorders



  • Glaucoma


  • Refractive error


  • Eye trauma

Vascular causes



  • Migraine headache


  • Migraine equivalent



  • Cocaine-induced headache


  • Cerebral arteritis

Psychiatric causes



  • Cyclical vomiting syndrome


  • Psychogenic vomiting


  • Self-induced (anorexia, bulimia)


  • Concealed vomiting


  • Erotic vomiting


  • Conditioned reflexes


  • Drug withdrawal


  • Rumination syndrome


Gastrointestinal Disorders

Mechanical intestinal obstruction (see 4-I)

Inflammatory



  • Gastroesophageal reflux disease


  • Peptic ulcer disease


  • Gastritis


  • Alkaline gastritis


  • Crohn disease


  • Eosinophilic gastroenteritis


  • Graft-versus-host disease


  • Pneumatosis intestinalis


  • Intestinal ischemia


  • Gastrointestinal sarcoidosis

Mass effect



  • Pancreatic pseudocyst


  • Carcinoma/lymphoma of gastrointestinal tract or pancreaticobiliary system


  • Abdominal carcinomatosis


  • Duodenal hematoma


  • Prior gastric surgery


  • Intussusception


  • Enterocele


  • External compression due to genitourinary tumors

Visceral pain



  • Referred pain


  • Pancreatitis


  • Cholecystitis


  • Biliary stricture


  • Choledocholithiasis


  • Appendicitis


  • Esophageal rupture/Boerhaave syndrome



  • Abdominal trauma


  • Peritonitis


  • Perforation

Functional intestinal obstruction



  • Gastroparesis



    • Diabetes


    • Scleroderma


    • Amyloidosis


    • Metabolic


    • Postoperative (postvagotomy)


    • Postviral


    • Idiopathic


    • Medication induced (i.e., narcotics)


  • Pseudo-obstruction



    • Chronic idiopathic intestinal pseudo-obstruction


    • Colonic pseudo-obstruction (Ogilvie syndrome)


  • Adynamic ileus


  • Gastric motility disorders


  • Irritable bowel syndrome


  • Nonulcer dyspepsia


Pregnancy

Nausea and vomiting of pregnancy

Hyperemesis gravidarum

Acute fatty liver of pregnancy


Infections

Acute infections (especially children)

Systemic infections and sepsis

Food poisoning

Bacterial/viral gastroenteritis

Helicobacter pylori infection

Hepatitis

Epidemic vomiting (Norwalk, Hawaii agent, etc.)

Intestinal or biliary parasitic infestations

Gastric herpes, cytomegalovirus (CMV) (immunocompromised host)

Acquired immunodeficiency syndrome (AIDS)


Endocrine and Metabolic Disorders

Diabetic ketoacidosis

Metabolic acidosis


Uremia

Hypercalcemia

Hyponatremia

Hypothyroidism

Hyperthyroidism

Hyperparathyroidism

Adrenal insufficiency

Pituitary adenomas


Genitourinary Disorders

Pyelonephritis

Obstructive uropathy

Renal calculi

Salpingitis

Endometritis

Endometriosis


Drugs

Chemotherapeutic agents

Antiarrhythmics

Antibiotics

Anticholinergic drugs

Cardiac glycosides (digitalis)

Ergot alkaloids

Estrogens, oral contraceptives

Theophylline

Colchicine

Narcotics

Ipecac

Potassium chloride


Toxins

Alcohol

Carbon monoxide

Carbon tetrachloride

Heavy metals

Illicit drugs


Other

Acute myocardial infarction

Congestive heart failure

Radiation sickness

Radiation therapy




References

1. Malagelada JR, Malagelada C. Nausea and vomiting, pp. 143-158. See Bibliography, 1.

2. Achord JL. Nausea and vomiting, pp. 41-48. See Bibliography, 2.

3. Hasler WL. Approach to the patient with nausea and vomiting, pp.760-780. See Bibliography, 3.


4-B. Dysphagia, Odynophagia


Oropharyngeal (Transfer) Dysphagia

Inflammation/infection



  • Herpes stomatitis


  • Monilial stomatitis


  • Viral or bacterial pharyngitis


  • Vincent angina


  • Retropharyngeal abscess


  • Peritonsillar abscess


  • Mumps


  • Stevens-Johnson syndrome

Structural abnormalities



  • Intrinsic



    • Postcricoid web


    • Zenker diverticulum


    • Upper esophageal stricture


    • Upper esophageal tumors


    • Head and neck tumors


    • Postsurgical change


    • Postradiation change


    • Foreign body


    • Congenital anomalies


  • Extrinsic



    • Dental anomalies


    • Cervical osteophyte


    • Thyromegaly


    • Cricopharyngeal bar


    • Cervical lymphadenopathy


    • Vascular anomalies


Neurologic disorders



  • Central nervous system disorders


  • Cerebrovascular accident


  • Parkinson disease


  • Brainstem tumors


  • Alzheimer disease


  • Depression


  • Tardive dyskinesia and dystonia


  • Stiff-man syndrome


  • Cerebral palsy


  • Motor neuron disease (e.g., amyotrophic lateral sclerosis)


  • Multiple sclerosis


  • Poliomyelitis


  • Huntington chorea


  • Syringobulbia


  • Tabes dorsalis


  • Spinocerebellar degeneration


  • Cranial nerve diseases


  • Recurrent laryngeal nerve palsy


  • Cranial nerve injury


  • Rabies


  • Diphtheria


  • Peripheral neuropathies


  • Diabetic neuropathy


  • Lead poisoning

Neuromuscular diseases



  • Myasthenia gravis


  • Botulism

Skeletal muscle diseases



  • Muscular dystrophies



    • Oculopharyngeal dystrophy


    • Myotonic dystrophy


  • Polymyositis


  • Dermatomyositis


  • Connective tissue diseases



    • Scleroderma


    • Lupus erythematosus


    • Behçet disease


    • Mixed connective tissue disease


    • Rheumatoid arthritis


  • Metabolic myopathies



    • Hyperthyroidism


    • Hypothyroidism


  • Amyloidosis


Drug induced



  • Tardive dyskinesia


  • Steroid myopathy


  • Mucositis secondary to chemotherapy

Other causes



  • Cricopharyngeal dysfunction


  • Xerostomia



    • Medication induced


    • Sjögren syndrome


    • Radiation induced


Esophageal Dysphagia

Caustic ingestion

Inflammation/infection



  • Reflux esophagitis


  • Bile reflux esophagitis


  • Radiation esophagitis


  • Caustic ingestion


  • Medication-induced esophagitis


  • Esophageal trauma


  • Esophageal infection



    • CMV


    • Herpes simplex virus (HSV)


    • Idiopathic human immunodeficiency virus (HIV) ulcers


    • Esophageal moniliasis


  • Esophageal Crohn disease


  • Eosinophilic esophagitis


  • Esophageal sarcoidosis


  • Graft-versus-host disease


  • Behçet syndrome


  • Necrotizing esophagitis

Structural abnormalities



  • Intrinsic



    • Esophageal stricture


    • Esophageal carcinoma


    • Carcinoma of the gastric cardia


    • Esophageal benign tumor


    • Esophageal web (Plummer-Vinson or Patterson-Kelly syndrome)


    • Esophageal ring (e.g., Schatzki ring)


    • Midesophageal diverticulum


    • Epiphrenic diverticulum


    • Esophageal pseudodiverticulosis



    • Paraesophageal hernia


    • Esophageal foreign body


  • Extrinsic



    • Vascular ring


    • Cervical osteophyte


    • Carcinoma of the lung


    • Mediastinal lymphoma


    • Mediastinal tuberculosis


    • Pulmonary abscess


    • Empyema


    • Enlarged right atrium


    • Pericardial effusion


    • Enlarged aorta (dysphagia aortica)


    • Anomalous right subclavian artery (dysphagia lusoria)

Motility disorders



  • Primary



    • Achalasia


    • Nonspecific esophageal motility disorder


    • Nutcracker esophagus


    • Hypertensive lower esophageal sphincter


    • Diffuse esophageal spasm


  • Secondary



    • Scleroderma and other connective tissue diseases


    • Polymyositis


    • Dermatomyositis


    • Diabetes mellitus


    • Amyloidosis


    • Hyperthyroidism


    • Hypothyroidism


    • Chagas disease


    • Pseudoachalasia


    • Chronic idiopathic intestinal pseudo-obstruction


    • Alcoholism


    • Paraneoplastic syndrome



References

1. See Bibliography, 5.

2. DeVault KR. Dysphagia: symptoms of esophageal disease, pp. 109-119. See Bibliography, 1.

3. Clouse RE, Diamant NE. Esophageal motor and sensory function and motor disorders of the esophagus, pp. 855-904. See Bibliography, 1.


4. Shafi MA, Ergun GA. Swallowing disorders and dysphagia, pp. 11-18. See Bibliography, 4.


4-C. Abdominal Pain1


Abdominal Disorders

Inflammatory disorders



  • Peritoneum



    • Peritonitis (chemical or bacterial; see 4-J)


    • Subdiaphragmatic abscess


    • Familial Mediterranean fever


  • Hollow viscera



    • Gastritis


    • Duodenitis


    • Peptic ulcer disease


    • Gastroenteritis


    • Cholecystitis


    • Bacterial cholangitis


    • Vasculitis


    • Intestinal perforation


    • Meckel diverticulum


    • Appendicitis


    • Crohn disease


    • Colitis (idiopathic and infectious)


    • Diverticulitis


  • Solid viscera



    • Pancreatitis (see 4-K)


    • Hepatitis (see 4-O)


    • Pyelonephritis


    • Abscess (hepatic, splenic, pancreatic, perinephric, psoas)


    • Mesenteric lymphadenitis

Mechanical disorders



  • Hollow viscera



    • Intestinal obstruction



      • Adhesions


      • Incarcerated hernia


      • Enterocele


    • Intussusception


    • Cecal or sigmoid volvulus


    • Biliary tract obstruction (stones, strictures, malignancy)


    • Ureteral obstruction


    • Sphincter of Oddi dysfunction



  • Solid viscera



    • Acute capsular distention


    • Acute splenomegaly


    • Acute hepatomegaly (i.e., hepatitis, hepatic congestion)


    • Nephrolithiasis


  • Abdominal wall



    • Abdominal wall contusion


    • Abdominal wall hematoma

Neoplasms



  • Pancreatic tumors


  • Gastric tumors


  • Hepatic tumors, primary or metastatic


  • Ampullary/duodenal tumors


  • Colonic tumors


  • Small intestinal tumors


  • Abdominal wall tumors

Vascular disorders



  • Intra-abdominal bleeding


  • Ischemic colitis


  • Mesenteric artery insufficiency or thrombosis


  • Mesenteric venous thrombosis


  • Budd-Chiari syndrome


  • Infarction (especially liver, spleen)


  • Omental ischemia


  • Abdominal aortic aneurysm

Functional disorders



  • Irritable bowel syndrome


  • Nonulcer dyspepsia


  • Sphincter of Oddi dysfunction


  • Functional constipation


  • Functional abdominal pain syndrome


Pelvic Disorders

Inflammatory disorders



  • Pelvic inflammatory disease


  • Tubo-ovarian disease


  • Mittelschmerz


  • Endometritis


  • Endometriosis


  • Salpingitis


  • Fitz-Hugh-Curtis syndrome


  • Cystitis



  • Seminal vesiculitis


  • Epididymitis

Mechanical disorders



  • Ovarian cyst/torsion


  • Ectopic pregnancy


  • Distended bladder


  • Omental torsion

Neoplasms



  • Cervical


  • Ovarian


  • Uterine


  • Bladder


  • Prostate


Extra-abdominal Disorders

Thoracic



  • Esophagitis


  • Esophageal spasm


  • Esophageal rupture (Boerhaave syndrome)


  • Myocardial infarction or ischemia


  • Pericarditis


  • Myocarditis


  • Endocarditis


  • Congestive heart failure


  • Pneumonia


  • Pulmonary embolism or infarction


  • Pneumothorax


  • Empyema


  • Pleuritis


  • Costochondritis

Neurologic



  • Radiculitis



    • Herpes zoster (shingles)


    • Degenerative arthritis


    • Herniated intervertebral disc


    • Spinal or peripheral nerve tumors


  • Causalgia


  • Tabes dorsalis


  • Abdominal epilepsy

Hematologic



  • Leukemia


  • Lymphoma


  • Sickle cell anemia



  • Hemolytic anemia


  • Henoch-Schönlein purpura

Toxins



  • Insect bite


  • Snake bite


  • Lead poisoning

Metabolic disorders



  • Uremia


  • Diabetes mellitus


  • Diabetic ketoacidosis


  • Acute adrenal insufficiency (Addison disease)


  • Porphyria cutanea tarda


  • Hypercalcemia


  • Hyperparathyroidism


  • Hypertriglyceridemic pancreatitis


  • Hereditary angioneurotic edema

Psychiatric disorders



  • Depression


  • Anxiety disorders


  • Schizophrenia


  • Factitious abdominal pain


  • Munchausen syndrome


Miscellaneous/Rare Causes

Migraine with abdominal pain

Hereditary angioedema

Omental infarction following abdominal surgery

Anterior abdominal wall hematoma or neuroma

Acute glaucoma

Narcotic withdrawal

Heat stroke

Unexplained intractable abdominal pain



References

1. Glasgow RE, Mulvihill SJ. Acute abdominal pain, pp. 87-98. See Bibliography, 1.

2. Kuo B. Chronic abdominal pain, pp. 99-108. See Bibliography, 1.

3. Haubrich WS. Abdominal pain, pp. 11-29. See Bibliography, 2.

4. Pasricha PJ. Approach to the patient with abdominal pain, pp. 781-801. See Bibliography, 3.



4-D. Characteristic Location of Abdominal Pain Associated with Various Diseases1


Diffuse

Gastroenteritis

Peritonitis

Pancreatitis

Leukemia

Sickle cell crisis

Early appendicitis (may be periumbilical)

Mesenteric adenitis

Mesenteric thrombosis

Abdominal aortic aneurysm

Intussusception

Colitis

Intestinal obstruction

Inflammatory bowel disease

Metabolic, toxic, bacterial causes


Epigastric

Reflux esophagitis

Peptic ulcer disease

Pancreatitis

Gastritis

Cholecystitis

Myocardial ischemia

Pericarditis

Abdominal wall hematoma


Right Upper Quadrant

Cholecystitis

Choledocholithiasis

Hepatitis

Hepatic neoplasms or metastases

Hepatic abscess

Hepatomegaly resulting from congestive heart failure

Ruptured hepatic cyst or neoplasm

Budd-Chiari syndrome (hepatic vein obstruction)

Peptic ulcer

Pancreatitis

Retrocecal appendicitis

Renal pain

Herpes zoster


Pulmonary infarction

Pleuritis


Left Upper Quadrant

Gastritis

Peptic ulcer disease

Pancreatitis

Splenomegaly or splenic rupture

Infarction, aneurysm

Renal pain

Herpes zoster

Myocardial ischemia

Pericarditis

Pneumonia

Empyema

Pulmonary infarction

Pleuritis


Right Lower Quadrant

Appendicitis

Neutropenic enteritis/colitis

Intestinal obstruction

Crohn disease

Diverticulitis

Cholecystitis

Perforated ulcer

Leaking aortic aneurysm

Abdominal wall hematoma

Ectopic pregnancy

Ovarian cyst or torsion

Salpingitis

Mittelschmerz

Endometriosis

Ureteral colic

Renal pain

Seminal vesiculitis

Psoas abscess


Left Lower Quadrant

Diverticulitis

Intestinal obstruction

Colon cancer

Appendicitis


Leaking aortic aneurysm

Inflammatory bowel disease

Abdominal wall hematoma

Splenomegaly

Ectopic pregnancy

Mittelschmerz

Ovarian cyst or torsion

Salpingitis

Endometriosis

Ureteral colic

Renal pain

Seminal vesiculitis

Psoas abscess

Irritable bowel syndrome


4-E. Constipation


Behavioral/Psychiatric Factors

Low-residue diet

Chronic laxative and/or enema abuse

Immobility

Reduced food intake

Encopresis

Psychosis

Depression

Eating disorders

Obsessive/compulsive disorders


Functional Constipation

Idiopathic constipation

Irritable bowel syndrome

Colonic inertia

Outlet delay, anismus

Fecal impaction

Pseudo-obstruction


Gastrointestinal Disorders

Colonic extraluminal obstruction



  • Intra-abdominal or pelvic tumors


  • Chronic volvulus


  • Hernias


  • Rectal prolapse


  • Ascites



  • Late pregnancy


  • Adhesions

Colonic luminal obstruction



  • Carcinoma of the colon or rectum


  • Benign colonic tumors


  • Recurrent diverticulitis


  • Diverticular stricture


  • Colonic stricture


  • Chronic ulcerative colitis


  • Eosinophilic colitis


  • Chronic amebiasis


  • Lymphogranuloma venereum


  • Syphilis


  • Tuberculosis


  • Ischemic colitis


  • Endometriosis


  • Postsurgical abnormalities


  • Intussusception


  • Sigmoidocele


  • Corrosive enemas

Anorectal disorders



  • Proctitis (especially ulcerative)


  • Hemorrhoids


  • Fissures and fistulas (e.g., Crohn disease)


  • Perianal abscess


  • Rectal prolapse


  • Anterior mucosal prolapse


  • Anal atresia or malformation


  • Anal stenosis


  • Solitary rectal ulcer syndrome


  • Internal intussusception


  • Hereditary internal anal sphincter myopathy


  • Carcinoma of the rectum or anus


  • Ulcerative proctitis


  • Lymphogranuloma venereum


  • Postsurgical


  • Descending perineum syndrome


  • Rectocele


Endocrine/Metabolic Causes

Hypothyroidism

Hypercalcemia

Porphyria cutanea tarda


Pheochromocytoma

Panhypopituitarism

Diabetes mellitus

Uremia

Hypokalemia

Heavy metal poisoning

Pregnancy

Glucagonoma

Pseudohypoparathyroidism


Neuromuscular Disorders

Parkinson disease

Cerebral palsy

Cerebrovascular accident

Brain tumors

Senile dementia

Multiple sclerosis

Tabes dorsalis

Spinal lesions

Aganglionic megacolon (Hirschsprung disease)

Neurofibromatosis

Multiple endocrine neoplasia type 2b

Diabetic autonomic neuropathy

Chagas disease

Familial visceral myopathy

Muscular dystrophies

Likongo syndrome (hindgut dysgenesis)

Scleroderma

Amyloidosis

Hypoganglionosis and hyperganglionosis

Intestinal pseudo-obstruction

Dermatomyositis


Drugs

Antacids



  • Calcium carbonate


  • Aluminum hydroxide

Opiates

Anticholinergics

Anticonvulsants

Tricyclic antidepressants

Ganglionic blockers

Phenothiazines


Ferrous sulfate

Antihypertensives



  • Diuretics


  • Clonidine


  • Calcium channel blockers

Barium sulfate

Bismuth compounds

Ion exchange resins

Antispasmodics

Antidepressants

Antipsychotics

Calcium supplements

Sucralfate

Cholestyramine

Monoamine oxidase (MAO) inhibitors

Analgesics

Vinca alkaloids



References

1. Patel SM, Lembo AJ. Constipation, pp. 221-254. See Bibliography, 1.

2. Koch TR. Constipation, pp. 102-112. See Bibliography, 2.

3. Wald A. Approach to the patient with constipation, pp. 894-910. See Bibliography, 3.


4-F. Diarrhea


Acute Diarrhea

Infections



  • Viral gastroenteritis (adenovirus, Norwalk agent, rotavirus, etc.)


  • Bacterial



    • Invasive (e.g., Shigella, Salmonella, Campylobacter, Escherichia coli, Yersinia)


    • Toxigenic (e.g., Staphylococcus, E. coli, Clostridium difficile, Vibrio spp., toxic shock syndrome, ciguatera toxin)


  • Mycobacterial (e.g., Mycobacterium avium complex)


  • Food poisoning



    • Staphylococcus aureus


    • Bacillus cereus


    • Clostridium perfringens



  • Protozoal (e.g., amebiasis, giardiasis, Cryptosporidium, Cyclospora, microsporidia, Isospora belli)


  • Fungal (e.g., Histoplasma, Cryptococcus, Candida)


  • Viral (e.g., CMV, HSV, adenovirus)


  • AIDS enteropathy

Stress induced

Food allergy (rare)

Dietary indiscretion (e.g., prunes, unripe fruit, rhubarb, olestra)

Gastrointestinal disorders



  • Partial bowel obstruction


  • Fecal impaction


  • Diverticulitis


  • Appendicitis


  • Ischemic bowel disease


  • Initial attack of ulcerative colitis or Crohn disease

Systemic/extraintestinal disorders



  • Uremia


  • Carcinoid syndrome


  • Zollinger-Ellison syndrome


  • Thyrotoxicosis


  • Addisonian crisis


  • Pelvic inflammation

Drugs/toxins (partial list)



  • Laxatives (poorly absorbable sugars, fiber)


  • Antibiotics


  • Magnesium-containing antacids/products


  • Colchicine


  • Digitalis


  • Iron


  • Antihypertensives (methyldopa, hydralazine, and others)


  • Quinidine


  • Antidepressants (e.g., Prozac, Wellbutrin)


  • Valproic acid


  • Antiretrovirals


  • Protease inhibitors


  • 5-Aminosalicylic acid products


  • Metformin


  • Interferon products


  • Immunosuppressives (cyclosporine, tacrolimus)


  • Potassium preparations


  • Nonsteroidal anti-inflammatory drugs (NSAIDs)



  • Lipid-lowering agents


  • Alcohol


  • Heavy metals (especially arsenic, cadmium, mercury)


  • Mushrooms

Acute exacerbation of chronic diarrhea


Chronic Diarrhea

Osmotic diarrhea



  • Carbohydrate malabsorption



    • Ingestion of poorly absorbable carbohydrates (sorbitol, mannitol, fructose, lactulose, fiber)


    • Congenital disaccharidase deficiencies


    • Lactase deficiency


    • Isomaltase-sucrase deficiency


    • Trehalase deficiency


    • Acquired disaccharidase deficiencies



      • Nontropical sprue


      • Tropical sprue


      • Viral gastroenteritis


  • Maldigestion syndromes (see 4-G)


  • Malabsorption syndromes (see 4-G)


  • Osmotic solutes



    • Magnesium-containing laxatives, antacids, or nutritional supplements


    • Sodium citrate


    • Sodium phosphate


    • Sodium sulfate


    • Polyethylene-glycol lavage solution


    • Enteral feedings


  • Reduced absorptive surface



    • Intestinal resection


    • Intestinal bypass


  • Other osmotic causes



    • Congenital chloridorrhea


    • Postgastrectomy “dumping” syndrome

Secretory diarrhea

Tags:
Jun 19, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Gastrointestinal and Hepatic System

Full access? Get Clinical Tree
Get Clinical Tree app for offline access