Page 150 - Medicine and Surgery

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146 Chapter 4: Gastrointestinal system

endoscopic assessment and therapy after adequate re- X-rays are taken serially following administration of
suscitation. the contrast. Advantages of contrast studies over endo-
In non-variceal bleeding failure of endoscopic therapy scopic procedures:

or further bleeding after a second endoscopic treat- No requirement for sedation, relatively well-tolerated.
ment is an indication for surgery. Motility can be assessed.
Low risk of perforation, particularly where anatomy

Prognosis is thought to be distorted by previous surgery.
Ninetypercentofhaemorrhagesoriginatingfrompeptic The main disadvantage is lack of ability to biopsy to
ulcers will stop spontaneously. Indicators of poor prog- obtain a tissue diagnosis and to treat, e.g. by removal of
nosis and recurrent bleeds: polyps or stop gastrointestinal bleeding.
Haematemesis and melaena together.

Age over 60years. Barium swallow

Shock (pulse >100 and systolic BP <100 mmHg). X-rays of the oesophagus are taken as the patient swal-

Co-morbidity (including obesity). lowscontrastintheerectandpronepositions.Ifassessing

Young patient with postural drop >20 mmHg. for dysphagia, bread may be given with the contrast to

demonstrate how solids move through the oesophagus.
Reflux may be seen in the erect or prone position.
Pruritus ani
Diagnoses that may be made include candidiasis, oe-
Pruritus ani is often idiopathic. Causes include the fol- sophageal webs, pouches, stricture and carcinoma, ex-
lowing: trinsic compression and achalasia.
i Lack of hygiene is the most common cause.
ii Skin conditions such as psoriasis or lichen planus. Double-contrast barium meal
Contact eczema may occur due to cream/lotion ap- Barium is given together with effervescent tablets; this
plication. raises the diagnostic accuracy to 80–90% for peptic ul-
iii Infections include candida especially in diabetic and cer disease as there is an additional contrast between
immunosuppressed, lice and anal warts. Thread barium and air. Features of a malignant gastric cancer
wormsinchildren. include a protruding mass into the lumen with a crater
iv Gastrointestinal disorders causing an anal discharge (ulcer) on its surface, interrupted nodular or irregular
may result in pruritus. folds around a crater and the stiff ‘leather-flask’ appear-
v Drugs such as quinidine and colchicine may cause ance(linitusplastica)ofdiffusegastriccarcinoma(which
pruritus if used long term. may be missed on endoscopy).
Proctoscopy and sigmoidoscopy may be required to
examine for rectal disease. Management where the Small bowel follow-through
primary cause cannot be identified or treated includes Barium is swallowed (without effervescent tablets) and
discontinuation of all local preparations and careful at- X-rays taken as it passes through the small intestine. In
tention to local hygiene. Surgical denervation has been both barium meals and follow-through, compression of
attempted with varying success. the abdominal wall may be required to visualise more
thoroughly.
Investigations and procedures
Barium enema
Patients are given a low residue diet for 3 days prior
Barium (contrast) studies
to the procedure, with powerful laxatives to cause pro-
Barium is a radiopaque material that is not absorbed, so fuse, watery diarrhoea to clear the large bowel. Barium
when swallowed or used as an enema can be used to de- and air are insufflated into the rectum via a catheter.
lineate the internal markings of the gastrointestinal tract The patient has to be tipped head-down and rotated to
and to assess gut motility. Water-soluble contrast should obtain various views of the entire colon, including the
be used if there is significant risk of leakage of contrast terminal ileum in some cases. The procedure can be un-
outsidethelumen(e.g.ifassessingforanastomoticleak). comfortable, unpleasant and requires the patient to be