PHYSICAL DIAGNOSIS EXAMINING THE GI SYSTEM

1. PHYSICAL DIAGNOSIS EXAMINING THE GI SYSTEM Stephen J. Goldberg, M. D. Phone: 513.686.5444

2. HISTORY - GETTING THE FACTS • General nutrition/appetite • Swallowing/esophagus • Upper GI/stomach • Digestion/intestinal • Elimination/colon

3. GENERAL NUTRITION • Stability of weight • Appetite • Excessive • Decreased • Mechanical problem • Early satiety • Depression

4. SWALLOWING/ESOPHAGUS - SYMPTOMS • Dysphagia • Polyphagia • Odynophagia

5. DYSPHAGIA - any difficulty in swallowing • Anatomical localization? • Solids vs liquids vs everything • Intermittent vs continuous • Associated weight loss? • Appetite?

6. POLYPHAGIA - excessive eating; gluttony • Associated weight changes? • Uncontrolled diabetes • Malabsorption • Psychological problem

7. ODYNOPHAGIA - painful swallowing • Anatomical localization? • Intermittent vs continuous • Associated problems • Immunosuppressed • Weight loss

8. UPPER GI/STOMACH - symptoms • Anorexia • Nausea • Emesis • Hematemesis • Heartburn

9. ANOREXIA - loss of appetite • Subjective symptom; look for objective findings • Duration • Weight loss? • Continuous vs intermittent

10. NAUSEA - inclination to vomit • Means different things to different people • “Sick to stomach” • Subjective symptom; cannot be measured • Objective consequences? • Weight loss • Means of relief

11. EMESIS - vomiting • Nature of material • Quantity of material • Preceding nausea • Precipitating cause • Frequency • Consequences?

12. HEMATEMESIS - vomiting blood • Visible blood vs coffee-grind material • Implies potentially serious problem • Bleeding peptic ulcer • Gastritis • Esophagitis • Esophageal tear • Neoplasm • Bleeding esophageal varices • ?Antecedent events

13. HEARTBURN - substernal burning; pyrosis • Due to gastro-esophageal acid reflux • Means different things to different people • Objective measures • Precipitating factors • Mode of relief

14. DIGESTION/INTESTINAL - symptoms • Indigestion/Dyspepsia • Belching/Eructation • Borgborygmi • Bloating/Gas/Flatulence/Distension • Colic • Steatorrhea

15. INDIGESTION/DYSPEPSIA • Means different things to different people • INDIGESTION - failure to ?digest food properly • DYSPEPSIA - failure of ?stomach to ?digest food properly • Usually non-specific symptoms • Obtain precipitating factors • ?Mode of relief

16. BELCHING/ERUCTATION • Speaks for itself? • Forceful passage of gas from stomach thru esophagus • Does it signify disease or good health? • ?Gastroesophageal reflux • Rapid eating/swallowing air • Deliberate vs involuntary • ?a compliment to the chef? • Not to be confused with BURPING (burp = passive verb)

17. BORBORYGMI - audible bowel sounds • Rumbling or gurgling of intestinal contents • ?Significance

18. BLOATING/GAS/FLATULENCE/DISTENSION • Subjective vs objective symptoms • Depends on where the gas is and what it’s doing • May be a sign of disease • Malabsorption • Bacterial overgrowth • Obstruction • May be innocuous • Irritable bowel syndrome • Overeating

19. COLIC - spasmodic abdominal pain • Crescendo/decrescendo pattern • Visceral origin • May be anatomical or functional in origin • ANATOMICAL = obstruction • FUNCTION = erratic peristalsis

20. STEATORRHEA - passage of fatty stools • Difficult to document or quantify by history • May indicate fat malabsorption • Stools do not have to be loose to have increased fat

21. ELIMINATION/COLON - symptoms • Diarrhea • Constipation • Scybyla • Hematochezia • Melena • Tenesmus • Hemorrhoids

22. DIARRHEA - stool with increased liquid content • May be increased in frequency • May represent disease (increased secretion) • May represent pharmacologic effect (osmotic action) • May represent rapid peristalsis and inefficient fluid regulation (irritable bowel syndrome) • IS IT A CHANGE? • IS IT ASSOCIATED WITH ANYTHING BAD?

23. CONSTIPATION - having stool which is difficult to pass • May be decreased in frequency • May be harder (drier) than expected • May be smaller than expected • May be associated with discomfort from any of the above • Usually markedly decreased water content • IS IT A CHANGE? • IS IT ASSOCIATED WITH ANYTHING BAD?

24. SCYBALA - small, hard, round masses of stool • Handy medical term with little significance

25. HEMATOCHEZIA - passage of stool with fresh blood • Blood is visible, not occult • Explanation is mandatory • Most commonly from hemorrhoids • Most frequently associated with constipation • May be an early sign of colon cancer

26. MELENA - passage of stool which is black from digested blood • Characteristic color and odor • Signifies digested blood from UGI origin • Signifies a significant blood loss

27. TENSEMUS - rectal pain • Suggests proctitis • Infection • Inflammatory bowel disease • May be due to spasm (irritable bowel syndrome)

28. HEMORRHOIDS - anal varicosities • Also known as “piles” • “Internal” • Not palpable • Bleed • May prolapse • Usually no discomfort • “External” • Visible • Painful at times

29. Precipitating factors Relation to meals Time of day Position ?Predictability ?Explainable on a physiologic basis Localization LLQ-->sigmoid,gyn RLQ-->terminal ileum, gyn, appendix, sigmoid? LUQ-->splenic flexure, ?pancreas Epigastric--> stomach, pancreas RUQ-->liver, gall bladder, duodenum EVALUATING GI SYMPTOMS-1

30. Symptom duration Continuous--> pancreatitis? Post-prandial--> mal-digestion? acid? obstruction? Wax/wane--> visceral? Symptom relief Eating --> acid neutralization Position - ->sedation, pancreatitis? Passage of flatus --> colonic distension? Bowel movement--> colonic distension?  peristalsis? EVALUATING GI SYMPTOMS-2

31. Weight loss? Family history Carcinoma Peptic ulcer disease Gallstones Inflammatory bowel disease Cirrhosis Abdominal surgery Travel history Military history Lifestyle Alcohol Substance abuse Sexually transmitted diseases (STD) Medications Uses Adverse effects ADDITIONAL HISTORICAL INFORMATION

32. TERMS Striae - stripe or line in skin distinguished by color or texture Scaphoid - concave Tympany- resonant sound Bruit - “abnormal vascular sound heard on auscultation” TERMS Fissure - break or slit in tissue Fistula - abnormal passage between two organs or structures, permitting passage of fluids or secretions PHYSICAL EXAM 1

33. LANDMARKS Costal margin Xiphoid process Pubic tubercle Inguinal ligament Anterior superior iliac spine Iliac crest Umbilicus LANDMARKS Quadrants RUQ, LUQ RLQ, LLQ Ninths Epigastrium (2) Peri-umbilical (5) Hypogastrium (8) SEQUENCE Inspection  Auscultation  Percussion  Palpation PHYSICAL EXAM 2The Basics

34. PHYSICAL EXAM 2Prerequisites for examination • Patient should have empty bladder • Patient should be supine • Examiner should be to right of patient • Examiner should be prepared to explain each step of examination • Examiner should be watching patient for signs of discomfort

35. PHYSICAL EXAM 3 • INSPECTION • SYMMETRY • CONTOUR • Flat • Scaphoid • Protuberant • SKIN • MASSES • PULSATIONS, PERISTALSIS

36. PHYSICAL EXAM 4 • AUSCULTATION • Bowel sounds ?Normal, ?Increased, ?Decreased, ?Absent • Bruits • Renal • Hepatic • Iliac • Femoral

37. PHYSICAL EXAM 5 • PERCUSSION • Liver span – percuss downward from chest, upward from abdomen • Normal span 6-12 cm • Stomach, bowel gas • Masses • Ascites • Spleen?

38. ASCITESIntraperitoneal fluid • Fluid wave • Ballottment • Contour • Shifting dullness Percuss abdomen to outline dullness/tympany Have patient roll away from you Percuss again to outline dullness/tympany If dullness has shifted to areas of prior tympany, ascites may be present

39. PHYSICAL EXAM 6 • PALPATION • Liver • Spleen • Tenderness/rebound • Sigmoid • ?Cecum • ?Aorta • ?Kidney • ?Gall bladder

40. PALPATING THE LIVER • Standard method • Stand facing patient and place fingers below right costal margin and press firmly • Have patient take a deep breath • Alternate method • Stand beside patient’s chest and hook fingers just below right costal margin • Have patient take a deep breath NORMAL LIVER SPAN = 6-12 CM AT RIGHT MID-CLAVICULAR LINE

41. PALPATING THE SPLEEN • The patient lies in the supine position • The examiner uses left hand to lift left lower rib cage • The examiner exerts pressure with right hand just below left costal margin • The patient takes a deep breath THE SPLEEN IS NOT NORMALLY PALABLE IN ADULTS

42. REBOUND TENDERNESSDetects peritoneal irritation • Examiner presses deeply on abdomen • Examiner quickly releases pressure after a moment • If sudden release of examining hand  pain, then rebound tenderness is present  peritoneal irritation

43. PALPABLE GALL BLADDER? • Courvoisier’s sign • Palpable gall bladder, no jaundice ==> cystic duct stone • Palpable gall bladder, jaundice ==> carcinoma • Non-palpable gall bladder, jaundice ==> common duct stone(s)

44. Jaundice Spider angiomata Palmar erythema Gynecomastia Ascites Asterixis Signs of portal hypertension Feminization of truncal hair pattern ?Parotid enlargement ?Testicular atrophy MANIFESTATIONS OFCHRONIC LIVER DISEASE

45. ANORECTAL EXAMINATION • External hemorrhoids • Anal tone • Warts • Tenderness • Prostate • Polyps/rectal masses • Stool for occult blood exam (HEMOCCULT)

46. NUTRITIONAL STATUS • General Appearance • Muscle mass • Skin turgor/redundancy/striae • Skin-fold thickness