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Tufts OpenCourseware
Author: Kanchan Ganda, M.D.

1. Gastrointestinal Dysfunctions and Diseases

1.1. Anorexia Nervosa

Anorexia Nervosa is the loss of appetite and body mass as the patient stops eating.

1.2. Bulimia

Bulimia involves a binging and purging type of behavior after the patient has eaten well.

1.3. Aphthous Ulcerations

Aphthous ulcerations affect the oral cavity and are due to stress, anemia, vitamin deficiencies, chemotherapy, etc. Patient may have a sore tongue because of aphthous ulcerations. They are often recurrent, painful, single or multiple.

1.4. Angular Cheilitis

Angular cheilitis occurs frequently because of iron deficiency anemia or in association with ill-fitting dentures, HIV, etc.

1.5. Candidiasis

Candidiasis can occur in the oral cavity because of stress; decreased immunity due to HIV, radiation or chemotherapy; ill-fitting dentures; broad-spectrum antibiotic intake; poorly controlled diabetes (very common cause of candidiasis); and iron deficiency anemia.

Oral candidiasis may be associated with esophageal candidiasis. If esophageal candidiasis is present, the patient will complain of dysphagia (difficulty swallowing) and/or odynophagia (painful swallowing).

1.6. Viral Pharyngitis

Viral pharyngitis may show mild redness, minimal swelling of the tonsilar pillars and frequently prominent lymphoid patches on the posterior pharynx. Watery eyes and runny nose are commonly associated symptoms.

1.7. Streptococcal Pharyngitis

Streptococcal pharyngitis classically produces redness and swelling of the tonsils, uvula and pillars along with yellow or white patches of exudate on the tonsils. Strep pharyngitis may occasionally occur without exudates. Accurate clinical diagnosis can only be made with positive throat cultures. Watery eyes and runny nose does not occur with bacterial infections.

1.8. Dysphagia

Dysphagia is difficulty swallowing. The patient complains of a feeling “as if food is stuck” and “won’t go down.” Dysphagia may be due to disorders of the mouth and pharynx, but difficulties experienced at a lower point are esophageal in origin.

1.9. Odynophagia

Odynophagia is dysphagia with pain. Odynophagia is commonly experienced by AIDS patients suffering from esophageal candidiasis. If dysphagia is associated with solids and not liquids, mechanical narrowing of the esophagus is a frequent cause. If dysphagia occurs with liquids, esophageal muscles may be the cause.

1.10. Heartburn

Heartburn is a common complaint by patients. Indigestion, reflux esophagitis, hiatus hernia, and peptic ulceration are common causes. Occasionally angina pectoris may mimic heartburn.

1.11. Hiatus Hernia

Hiatus hernia is associated with the stomach sliding into the thoracic cavity through a very patent opening in the diaphragm, when the patient lies down in bed. The heartburn decreases when the patient uses a few pillows to prop him/herself up in bed. If hiatus hernia is present, it will cause worsening of heartburn on laying down in bed. Hiatus hernia can cause gastroesophageal bleeding just as in a peptic ulcer patient. So always ask the patient if they have black or tarry stools—if present, it is indicative of upper gastrointestinal (GI) bleed.

1.12. Peptic Ulceration or Gastritis

Peptic ulceration or gastritis causes epigastric pain. The pain of gastric ulceration is relieved with food, whereas a duodenal ulceration pain comes on two hours after the patient has eaten. Peptic ulceration, gastritis and hiatus hernia can cause upper GI bleeding resulting in black, tarry stools. Always check for a history of chronic intake of aspirin, NSAIDs or steroids in patients complaining of heartburn, hiatus hernia and peptic ulceration.

1.13. Coeliac Disease and Crohn’s Disease

The small intestines may be affected with Coeliac Disease or Crohn's Disease which leads to malabsorption of iron, folic acid and vitamin K. The patient can suffer from anemia and deep tissue bleeding problems. Small bowel disease is often associated with weight loss, foul smelling, bulky stools and diarrhea.

1.14. Ulcerative Colitis and Diverticulitus

Large bowels can be affected by ulcerative colitis and diverticulitus. Bleeding from these sites causes fresh blood in the stools. Fresh blood in the stools indicates lower GI bleeding. Pain and cramping is a common complaint with diverticulitis. Chronic diarrhea or constipation is common. Corticosteroids are often prescribed during acute exacerbation of inflammatory bowel conditions. Codeine phosphate is often not given to these patients because of its constipating effect, this is an important point to note for those patients suffering from constipation.

1.15. Jaundice (icterus)

Jaundice is a yellowish discoloration of the skin and sclera due to increased levels of bilirubin. Bilirubin is a bile pigment which results from a breakdown of hemoglobin. Normally, the bilirubin is taken up by the liver cells, conjugated (combined) , and made water soluble. This then gets excreted in the bile via the biliary tree into the small intestine. When jaundice occurs, bilirubin in the blood may be of the conjugated or unconjugated type or both. Unconjugated bilirubin can occur with hemolytic anemia when there is an increased production of hemoglobin; decreased uptake of bilirubin by the liver cells; or inability of the liver to conjugate bilirubin as there is such large amounts of hemoglobin coming to the liver.

When excretion of bilirubin is impaired, the bilirubin in the blood is mainly conjugated as in obstruction caused by bile stones or gallstones (obstructive jaundice). Viral hepatitis may also cause elevated levels of conjugated bilirubin. When conjugated bilirubin increases in the blood, it may appear in the urine, resulting in a “Cola colored” or “dark-colored” urine. Unconjugated bilirubin is not excreted in the urine.

When excretion of bile into the intestine is obstructed, the “normal yellowing” of the stools is lost and the stools thus appear white or acholic. Thus, acholic stools are a frequent manifestation of obstructive jaundice.