Makindo Medical Notes

Related Subjects: |Upper Gastrointestinal Bleed |Oesophageal Variceal Bleeding |Dieulafoy Lesion |Mallory-Weiss Tear |Gastric Cancer |Peptic Ulcer Disease |Oesophagogastroduodenoscopy (OGD/EGD) |Hereditary Haemorrhagic Telangiectasia |Hypovolaemic or Haemorrhagic Shock

Red flags include dysphagia, unplanned weight loss, anorexia, haematemesis and/or melaena, older age, lack of response to therapy, chronic symptoms, and being on long-term therapy.

Dysphagia

• Difficulty swallowing. Differentiate between gastroenterological and neurological causes.
• Gastroenterological dysphagia usually involves the oesophageal phase, with food "sticking" or being regurgitated rather than issues with the oral and pharyngeal phases.

Gastrointestinal Causes

• Achalasia: Typically seen in younger patients with regurgitation of undigested food soon after swallowing. Both solids and liquids may be held up at the lower oesophageal sphincter.
• Malignancy: Progressive dysphagia, initially to solids and then to liquids.
• Oesophageal Stricture: Often with a history of gastro-oesophageal reflux disease (GORD).
• Oesophageal Spasm: Painful swallowing, often with normal endoscopy but spasms visible on a barium swallow.
• Oesophageal Dysmotility: Common in older patients with GORD symptoms.
• Globus Hystericus: "Lump in the throat" sensation, often in anxious patients. ENT referral may be needed for reassurance.
• Hiatus Hernia
• Oesophagitis: Pain with swallowing.
• Pharyngeal Pouch: Leads to regurgitation of undigested food.

Neurological Causes

• Stroke affecting bulbar or pseudobulbar areas.
• Motor neuron disease.
• Myasthenia gravis.
• Parkinson's disease.

Odynophagia (Painful Swallowing)

• Common causes include oesophageal inflammation, oesophageal candidiasis, CMV infection, and chemical oesophagitis.
• Associated with certain medications (e.g., bisphosphonates), oesophageal malignancies, and oesophageal spasm.

Dyspepsia

• General term for abdominal discomfort, fullness, nausea, belching, and "wind."
• Causes: Inferior myocardial infarction (if acute), GORD, peptic ulcer disease, oesophagitis, stomach cancer, non-ulcer dyspepsia.

Weight Loss

• Reduced Calorie Intake: Due to loss of appetite, dyspepsia, nausea (e.g., from drugs or brain tumors), ENT issues, motor neuron disease, stroke, infection, dysphagia, psychiatric conditions (e.g., anorexia, depression, dementia).
• Despite Normal Calorie Intake: Cancer, hyperthyroidism, inflammatory diseases (e.g., Crohn's disease, ulcerative colitis, rheumatoid arthritis) must be considered.

Altered Bowel Habit

• Differentiate between increased frequency and diarrhoea.
• Causes of Increased Stool Frequency: Hyperthyroidism, anxiety, irritable bowel syndrome (IBS).

Diarrhoea (Stool Weight > 200g/24 hrs)

• Acute Diarrhoea: Infective causes, antibiotic-related (e.g., Clostridioides difficile), foodborne illness, ulcerative colitis flare.
• Subacute/Chronic Diarrhoea: Ulcerative colitis, Crohn's disease, laxative overuse, colorectal tumors or polyps, coeliac disease.

Steatorrhoea

• Pale, offensive-smelling, greasy stools due to fat digestion issues or malabsorption.
• Causes: Small bowel disease, pancreatic disease, biliary disease. Often associated with fat-soluble vitamin deficiencies (A, D, E, K).

Constipation

• Causes: Hirschsprung’s disease (in children), dilated atonic colon, IBS, aging, opioid use (e.g., codeine), hypothyroidism, dehydration, immobility, diverticular disease, left-sided colorectal tumors, Parkinson’s disease.

Tenesmus

• Sensation of incomplete rectal emptying after defecation.
• Common in IBS and rectal tumors.

Jaundice

• Cholestatic Jaundice: Dark urine and pale stools, often with right upper quadrant (RUQ) pain suggesting gallstones.
• Painless Jaundice with Weight Loss: Consider pancreatic tumor.
• Medication History: Some drugs may cause jaundice.
• Hepatitis A Risk Factors: Recent seafood intake or distaste for cigarettes.
• Hepatitis B Risk Factors: IV drug use, sexual contacts.
• Hepatitis C Risk Factors: IV drug abuse, transfusions.
• Leptospirosis Risk Factors: Canoeing, watersports.
• Alcohol Intake: High intake may lead to alcoholic liver disease.
• Other Causes: Haemolysis (mild jaundice), Gilbert’s syndrome (benign familial cause, worsened with fasting).

Haematemesis

• Bright red blood is a clear indicator, but note that not all dark or black material is blood—it could be bile.
• Causes: Duodenal or gastric ulcers, gastric erosions, Mallory-Weiss tear, oesophagitis, duodenitis, oesophageal varices, gastric/oesophageal cancer, angiodysplasia, hereditary haemorrhagic telangiectasia, aorto-duodenal fistula.

Melaena

• Dark, tarry stools often associated with upper GI bleeding, similar causes as haematemesis.