SIGNS AND SYMPTOMS OF GIT DISORDERS

1. SIGNS AND SYMPTOMS OF GIT DISORDERS M. JUFRI MAKMUR

2. DEFINITION Symptom : Subjective data of patient’s complaints Symptom is the most important thing in directing or guiding a diagnostic (60%) Sign : Objective data of physical findings Refferences: Adam’s Physical Dx HarissonSigns &Symptoms Barbara Bates A Guide to Physical Examination and History Taking

3. Diagnostic Procedure SOAP S  Subjective (identity, symptoms, clinical history, genetics) O  Objective (signs, laboratory, radiologic, etc) A  Assesment (diagnostic & DD) P  Planning (treatment, supporting examination)

4. Basic of Symptoms and Signs Anatomical - topography - vascularization Physiological - organ function - metabolism

5. TOPOGRAPHYAbdominal regionsnine regions system RHC LHC EPI RL LL UMB RI LI SP

6. Organ Function Esophagus - swallowing Gaster & Duodenum - digestive and absorbtion Liver - anabolism and catabolism - detoxification - eritropoesis extramedullar - bile secretion

7. Pancreas - hormone secretion - enzyme secretion • Colon - reabsorbtion - faecal formation • Rectal - faecal reservoar

8. SYMTOMPS • 1. Abdominal pain • 2. Abdominal distension • 3. Dysphagia • 4. Odinophagia • 5. Hiccup or Singultus • 6. Vomitus & Regurgitasion • 7. Bloating • 8. Hematemesis • 9. Melena • 10. Diarhea • 11. Constipation • 12. Hematochezia

9. 1. Abdominal pain - the most common symptom - location, type, cont. or intermitten, spread, referred - location depend on topographyc - due to : GIT ,TUG, Gyn, MSC, & CV - intermittent pain related to luminar organ (colic) - referred pain depend on innervasion

10. Types of abdominal pain: - epigastric pain  gastroduodenitis, pancreatitis, Inferior MCI, left liver abcess, hepatic disorders, lymphoma, aneurisma aorta - Biliary colic  pain from the right hypochondrial spread to right back shoulder  gallstone & CBD stone

11. - Renal colic  pain from back CVA spread to right iliac region obstructive uropathy - Right hypochondrial pain  hepatic disorders, gall disorders, pleuritis, TUG disorders, and colon disorders

12. - Left hypochondrial Pain  gastritis, pseudocyst pancreas, colon disorders TUG disorders, pleuritis, and spleen disorders - Umbilical pain  gastritis, enteritis, colitis, aneurisma aorta, trombosis of mesenteric artery - Right & Left Lumbal pain  colon disorders , TUG disorders, psoas abcess

13. - Right Iliac pain  appendicitis, colon disorders, psoas abcess, PID, ovary cyst, ileitis term., TUG dis. - Left Iliac pain  colon disorders, psoas abcess, PID, ovary cyst, TUG disorders

14. - Suprapubic pain  cystitis & bladder stone, gynaecologic disorders, prostat disorders, colo-rectal disorders - Whole abdomen pain  peritonitis, muscle pain, gastroenteritis, colitis

15. 2. Abdominal Distention Due to: gas, fluid, mass, organomegali With or without pain ? Acute, recurent, or chronic ? Bowel or micturia alteration ? Organ involved: GIT, TUG, Heart

16. 3. Dysphagia Difficulty swallowing Due to pain, obstruction, abn. peristalsis, or impaired reflex (nerve) Organ involved  esophagus or oropharynx Most common case: Stricture esophagus, malignancy, GERD, multiple sclerosis

17. 4. Odinophagia Pain of swallowing Organ involved  esophagus Due to inflammation process

18. 5. Hiccup or Singultus • Involuntary spasmodic contraction of the diaphragm followed by sudden closure of glottis • Due to increase of intracranial pressure, abdominal distention, gastric dilatation or inflammation, and renal failure, decrease serum levels of carbondioxide

19. 6. Vomitus & Regurgitation Reflux of gastric contents The difference  with or without contraction Involved vagal mechanism Non specific  all of GIT disorders

20. 7. Bloating • Full sensation of stomach • Due to inflammation, gastric emptying disorders, gastric mass, Increase of gastric pressure, increase of gas production, full or partial obstruction

21. 8. Hematemesis Bleeding of upper GIT (lig. treitz) Due to variceal rupture, ulcer, erotion, mass Organ involved  esophagus, stomach, & duodenum Life threatening symptoms

22. 9. Melena • Black bloody stool from upper GIT • Black color is due to oxidation of Hb • Caused and organ involved similar to hematemesis • Life threatening symptom

23. 10. Diarrhea Waterry stool more than 3 x/day Acute or chronic ? ( 2 weeks ) Due to reabsorbtion impairment (osmotic, toxin,etc) or hyperperistaltic (hyperthyroid) Organ involved  Intestinal and colorectal

24. 11. Constipation No defecation more than 3 days Due to obstruction, hypoperistaltic, inflammation, medication Organ involved  Colorectal

25. 12. Hematoschezia Fresh red bloody stool Due to lower GIT Haemorhoid is the most common cause of hematoschezia Acute,reccurent, or chronic ? Bowel habit alteration ?

26. Signs From physical findings Most common in hepatobilliary disorders General : vital sign Specific : inspection, palpation, percusion, and auscultation Gentle Right side of patients

27. 1. Mental Change Most common in end stage of cirrhosis or severe hepatic disorders Called as encephalopathy hepatic Due to false neurotransmitter (aromatic amino acids, ammonia) Sometimes accompanied by flapping tremor

28. 2. Icteric or Jaundice A yellow discoloration of the skin, mucous membranes, or sclera of the eyes Signs of excessive levels of conjugated or unconjugated bilirubin in the blood Type : Prehepatic, Hepatic, and Posthepatic Commonly accompanied by pruritus because bile pigment damage sensory nerve (hepatic or posthepatic jaundice)

30. Tea dark colored urine, clay colored stools always accoppany obstructive or posthepatic jaundice Prehepatic jaundice  hemolysis Hepatic jaundice  hepatic disorders, congestive liver (heart), systemic inflammation (sepsis, lupus), malignancy, and drugs Posthepatic jaundice  CBD stone, malignancy of billiary system, lymphoma

31. jaundice

32. 3. Gynecomastia Occuring only in males Increased breast size due to excessive mammary gland development Most common in cirrhosis Failure to inactivate circulating estrogen

33. 4. Spider Nevi/Angioma • A fiery red vascular lession with an elevated central body and a surrounding flush • Most common in face, neck, and chest • Related with cirrhosis and hyperestrogenemia (pregnancy)

34. 5. Palmar Erythema Local vasodilatation along palmar side Most common in cirrhosis Mechanism is unknown

35. 6. Ascites Accumulation of fluid in abdominal cavity Due to decrease of osmotic pressure (hypoalbumin) or increase of hydro-static pressure (portal hypertension) Signs  dullness in both flank, shifting dullness, undulation Nonspecific sign Most common in cirrhosis, gynaecologic dis., severe diseases, peritoneal tuberculous, renal and heart problem

36. Ascites ascites accumulation of fluid in the abdominal cavity

38. 7. Meteorismus Accumulation of gas in abdominal cavity Hypersonor percusion Bowel sound ? Metalic sound ? Pain ? Flatus ? Bowel Habit ? Due to electrolyte imbalance, drug, inflammation, total or partial obstructive

39. 8. Pain palpation Depend on tophographic Types: Murphy’s sign, Ludwig’s sign, CVA percussion pain, epigastric pain, Mc Burtney’s pain, defanse muscular, suprapubic pain

40. 9. Hepatomegaly • Hepatic enlargement subcostal • Confirmed by palpation, percussion, and sonographic • Due to systemic or hepatic problems • Important things  size, consistency, and pain

41. liver enlargement, portal hypertension

42. LIVER SPAN MCL PERCUSSION NL < 12-13 CM 2-3 CM DURING INSPIRATION AND EXPIRATION COPD PALPATION PERCUSSION SCRATCH TEST LIVER SPAN MAY VARY BETWEEN OBSERVERS DEPENDING UPON WHERE THE MCL IS DETERMINED JAMA 1994;271:1859-1865

43. PALPATION FLEX KNEES AND HIPS IF POSSIBLE BEGIN LOW ON ABDOMINAL WALL AND MOVE HAND CEPHALAD, HAVE PATIENT TAKE A DEEP BREATH NOTE CONSISTENCY (NODULES, SMOOTH) AND CONTOUR IF THE LIVER EDGE IS FELT NOTE IF THERE IS ANY PAIN WITH PALPATION AUSCULTATE MOSBY’S GUIDE TO THE PHYSICAL EXAMINATION, 3RD ED. 1995

44. 10. Splenomegaly Enlargement of spleen below of arcus costae Due to infection, trauma, portal hypertension, neoplastic, hematologic disorders Confirmed by palpation and sonograph

45. 11. Mass palpation • Depend on topographic (similar to abdominal pain) • Important things  size, consistency, mobility, and pain • Confirmed by sonograph, radiograph, and endoscopy

46. 12. Flapping Tremor Patognomonis sign of encephalopathy hepatic Tremor of wrist joint after full extension

47. 13. Pitting Edema • Accumulation of fluid in subcutis especially in plantar pedis • Due to hepatic, renal, heart, malnutrition, blood vessel, and systemic inflammation

48. Case Simulation • This lady have a fever since 1 weeks ago, abdominal distention in epigastric, vomitus, history of bloody diarhea, no history of dyspepsia before • What examinations should you perform to this patients? A young lady, married, 32 yo, came to hospital with chief complaint of epigastric pain localized What questions should you ask to this patient?

49. From examination, there are icteric, pain and palpable mass in epigastric, dark tea color urine, no cley-color stool, no defanse muscular What working diagnostic and differential diagnostic are possible in this patient?

50. The working dignostic in this patient is left lobe hepatic abcess • The differential diagnostic are pancreatic neoplasm, gastric mass, pseudocyst of pancreas, left lobe hepatoma, colon mass, lymphoma, aortic aneurism. • What are next examinations you suggested to confirm a diagnostic ? • What is the treatment ?