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♦ Vomiting of blood .
♦ Proximal to ligament of treitz.
♦ GI bleeding below duodenum rarely enters
♦ Colour of vomited blood depends on
1.Concentration of HCL acid
♦ 2.Duration of contact with acid.
Short duration—red color
Long duration—dark red,brown
black or cofee ground appearance.
♦ Black tarry stools.
♦ Sticky,loose with characteristic odour.
♦ HCL acts on Hb to produce haemetin giving
♦ Usaually follows hemetemesis.
♦ Both suggest proximal source.
♦ Bleeding from esophagus,stomach, small
gut and even ascending colon occasionally.
♦ 60 ml of blood –Single melena stool.
♦ More than this may lead melena upto 7
♦ Occult blood in stools remains positive for
weeks with normal stool colour.
♦ Black or dark gray stools may occur with
use of iron, bismith or licorice.
♦ Occult blood in stool—potentially serious.
♦ Passage of blood per rectum.
♦ Bleeding distal to ligament of treitz.
♦ Brisk proximal bleeding—rapid transit.
♦ Anal or rectal lesions like haemorrhoids or
♦ Colonic lesions like growth ,IBD ,infections
♦ Extent of bleeding.
♦ Rate of bleeding.
♦ Comorbid factors.
Extent of bleeding.
♦ Less than 500 ml of blood loss—rarely
associated with systemic signs.Exceptions
include elderly and anemic.
♦ Orthostatic hypotention—20% or greater
reduction in blood volume.
♦ Concomitant symptoms include
lightheadedness, syncope, nausea, sweating
♦ Blood loss upto 25-40%--Shock.
Common causes of upper GI
♦ Peptic ulcer
♦ Gastroduodenal erosions
♦ Mallory weiss tear
♦ Varices—Bleed is abrupt and massive.
♦ Underlying cirrhosis and portal
♦ 25% cases other sources like erosive
gastropathy and peptic ulcer.
♦ Stigma of CLD.
♦ Peptic ulcer—Break in gastric/duodenal
mucosa may extend through muscularis.
♦ 5 times more common in duodenum
♦ 95% in bulb or pyloric channel.
♦ NSAIDS ,H pylori, and acid hypersecretion.
♦ History suggestive.
♦ Erosions—Asprin and NSAIDS.
♦ Mallory weiss—Mucosal tear with retching
♦ Esophagititis—GERD ,infections and
Nausea and vomiting
♦ Nausea is a desire or feeling.
♦ Vomiting is forceful expulsion of gastric
♦ Retching is laboured rythmic contraction of
respiratory and abdominal musculature
precede or accompany vomiting.
Control of vomiting
♦ 2 distinct medullary centers.
♦ Vomiting center in dorsal part of lateral
reticular formation .
♦ CTZ area postrema of floor of fourth
♦ Vomiting center controls and integrates the
actual act of emesis.It receives inputs from
four different sources.
Impulses reaching vomiting
♦ Afferent vagal.
♦ Vestibular system.
♦ Higher centers.
♦ Area postrema.
Causes based on input
♦ Visceral afferent---Mechanical obstruction,
dysmotlity, peritonial irritation ,infection
,hepatobiliary or pancreatic and topical.
♦ CNS disorders(vestibular & higher centers)
middle ear diseases, increased ICP,CNS
♦ CTZ—irritation from drugs and systemic
♦ Temporal relations like early morning
houres, relation with meals and psychogenic
♦ Associated symptoms are important.
♦ Vertigo and tinnitis—Meniers disease.
♦ Long standing history with out significant
sequel point psychogenic.
♦ Localizing symptoms like in abdomen or
Character of vomitus.
Character of vomitus.
Large amount of acid.
Absence of acid.
Feculent or putrid odor.
Presence of blood.
EFFECTS OF VOMITING
♦ Upper abdominal or epigastric symptoms
including pain ,discomfort ,fulness ,bloating
early morning satiety,belching,heart burn,
regurgitation and indigestion.
25% of adult population
3% of OPD patients in west.
Vast majority in our OPDs.
Functial or non ulcer dyspepsia
♦ Most common.
♦ 70 % ------ no organic cause.
♦ Young age.
♦ Vague symptoms.
♦ Anxiety and depression.
♦ History of use of psychotropic drugs.
♦ Presence of more specific symptoms like weight
loss,dysphagia,hematemesis,malena and anemia
should be sought.
Heart burn or pyrosis
♦ Sensation of warmth.
♦ Retrosternal burning.
♦ 90% with GERD.
♦ Relation with large meals.
♦ Presence of provocative factors.
♦ Chronic repetitive eruction (belching) of
♦ Rapid eating.
♦ Use of carbonated beverages.
♦ Use of chewing gums,smoking and with
post nasal drip.
♦ Excessive sensetivity to normal impulses.
♦ Motility disorders.
♦ Foods like legumes, grain and beans.
♦ Infections like giardiasis.
♦ Sensation of sticking or obstruction to the
passage of food through mouth ,pharynx or
♦ Other symptoms related to swallowing
♦ Aphagia: Complete obstruction.medical
♦ Difficulty in initiating swallowing.
♦ Disorders of voluntary phase.
♦ Paralysis of tongue.
♦ Oropharyngeal ansthesia
♦ Lack of salivation.
♦ Lesions of vagus and glossopharyngeal nerves.
♦ Lesions of swallowing centers.
♦ Once initiated------Completed.
♦ Misdirection of food.
Characteristic of oropharyngial dysphagia.
Associated with nasal regurgitation,
laryngeal and pulmomary aspiration.
Fear of eating food.
Associated with Hysteria,Rabies and
♦ Globus pharyngeous.
Pathophysiology of dysphagia.
♦ Size of ingested bolus.
♦ Luminal diametre.
♦ Peristaltic contractions.
♦ Relaxtion of upper and lower esophageal
♦ Mechanical dysphagia.
Initially with solids and later with liquids.
♦ Motor dysphagia.
With both solids and liquids from onset.
♦ Luminal—Size of bolus.
Normal esophageal distention upto 4cm.
No dilatation beyound 2.5cm---Solids
dilatation beyound 1.3cm---Semi solids and
♦ Intrinsic narrowing.
Webs and rings.
Strictures and growth.
♦ Extrinsic Compression.
♦ Difficulty in initiating of swallowing.
♦ Abnormalities of peristalsis or deglutitive
inhibition due to diseases of esophageal
striated or smooth muscles.
♦ Important causes include pharyngeal
achlasia,scleroderma ,achalasia, esophageal
spasm and related motor disorders.
♦ Intermittent: Diffuse esophageal spasm.
♦ Mild progression—Motor disorder—
months to years.
♦ Rapid progression—Over weeks is
dangerous as may be associated with
obstruction and malignancy.Needs urgent
Approach to patient.
♦ Past history of GERD.
♦ Association with solids and liquids.
♦ Level of obstruction:
High cricoid cartilage-Difficulty with ejection of bolus.
Takes many swallows to clear.
May be associated with cough
& aspiration. Tumor,stricture, pharyngeal
pouch or reflux
♦ Lower sternum:
After successful swallow food is held
♦ Painful mouth or throat:
Recurrent aphthous ulcers,glandular
fever, tonsillitis and quinsy.
♦ Neurological involvement:
Bulbar or pseudobulbar palsy.
♦ Neuromuscular weakness:
♦ Obstruction:Cacinoma esophagus,stomach
or extrinsic compression by bronchial Ca.