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Propedeutics-Gastroenterology 1.

Propedeutics-Gastroenterology 1. History taking in abdominal diseases. History taking Abdominal pain. Localisation Type Severity Chronology Aggravating or relieving factors Associated symptoms Radiation of pain. Right upper quadrant (RUQ). Cholelithiasis, cholecystitis, cholangitis

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Propedeutics-Gastroenterology 1.

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  1. Propedeutics-Gastroenterology 1.

  2. History taking in abdominal diseases

  3. History takingAbdominal pain • Localisation • Type • Severity • Chronology • Aggravating or relieving factors • Associated symptoms • Radiation of pain

  4. Right upper quadrant (RUQ) • Cholelithiasis, cholecystitis, cholangitis • Duodenal ulcer • Pancreatitis • Hepatitis, hepatic congestion • Colon cancer • Nephrolithiasis, hydronephrosis, pyelonephritis • Pulmonary causes • Diaphragmatic pain

  5. Epigastric • Peptic ulcer • Gastro-oesophageal reflux disease • Pancreatitis • Cholecystitis • Intestinal obstruction • Gastric cancer • Functional dyspepsia • Myocardial infarction • Abdominal angina

  6. Left upper quadrant (LUQ) • Colon cancer • Colitis, irritable colon syndrome • Pancreatitis, pancreatic cancer • Splenic causes • Nephrolithiasis, hydronephrosis, pyelonephritis • Pulmonary causes • Diaphragmatic

  7. Periumbilical • Enteritis • Appendicitis (early) • Pancreatitis, pancreatic cancer • Intestinal obstruction • Aortic aneurysm • Abdominal angina

  8. Lumbar • Kidney stone • Pyelonephritis • Perinephritic abscess • Colon cancer

  9. Right lower quadrant (RLQ) • Appendicitis • Colon cancer • Crohn’s disease • Ureterolithiasis • Salpingo-oophoritis (adnexitis)

  10. Hypogastric • Cystitis • Salpingitis • Ectopic pregnancy • Prostatitis • Colonic pain

  11. Left lower quadrant (LLQ) • Diverticulitis • Colon cancer • Ulcerative colitis • Ureterolithiasis • Salpingo-oophoritis (adnexitis)

  12. Diffuse abdominal pain • Peritonitis • Intestinal obstruction • Irritable bowel syndrome • Tense ascites

  13. Acute abdomen • Peritonitis • Appendicitis • Bowel or gastric perforation • Gallbladder perforation • Intestinal obstruction (ileus) • Mesenterial ischaemia • Extrauterine pregnancy (ectopic pregnancy) • Acute necrotising pancreatitis • Biliary colic • Renal colic

  14. History takingOther causes abdominal pain • Diabetic ketoacidosis • Hyperthyroidism • Acute intermittent porphyria • Hypercalcemia, hyperkalemia • Vasculitis • Pneumonia • Sickle cell crisis • Herpes zoster

  15. Radiation of pain • Ulcer disease: to the back • Biliary pain: to the back, right scapula, right shoulder • Pancreatic: band-like, to the back • Kidney, ureter: to the genitalia, groin • Splenic: left shoulder

  16. Cardiac pain Radiation: left Type: pressing, constricting Aggravating factors: physical activity, stress Relieving factors: nitrates Associated symptoms: dyspnoea, sweating Esophageal pain Radiation : back Type:burning, spasmodic Aggravating factors: body position, eating Relieving factors: antacid Associated symptoms: dysphagia,regurgitation History takingSubsternal pain

  17. History takingDysphagia- difficulty in swallowing • Where is the food „hanging up”? oropharyngeal or esophageal • Difficulty to swallow liquids? • Progressive or constant or variable? • Odynophagia- painful swallowing • Globus hystericus- feeling lump in the throat

  18. History takingWeight loss • Is it associated with anorexia? • Chronology • Severity (significant:> 5% of body weight) • Underlying diseases • Causes: general disorders: diabetes, hyperthyroidism, chr.infections,malignancy, medications behavioral disorders: anorexia nervosa, depression GI disorders: malignancy, malabsorption, hepatic, biliary, pancreatic diseases

  19. History takingNausea and vomiting • Organic, functional or psychogenic? • connection with meals • accompanied by weight loss • Content of the vomit • Factors: taste, smell, colour • Subtypes: acid : reflux disease, duodenal ulcer • bile: bilio-pancreatic diseases • undigested food: obstruction of the upper GI • faeces (miserere): bowel obstruction (ileus) • blood: ie. ulcer, tumor, oes.varix

  20. History takingNausea and vomiting Causes • Mechanical obstruction • Dysmotility • Intraabdominal inflammations - paralytic ileus • Neural causes • Local - ie. diabetes, postvagotomy states • Central neural – ie. meningitis, intracranial mass, vestibular diseases • Metabolic - hypokalemia, hypothyreoidism, pregnancy, renal failure • Other • Myocardial infarction • Drugs • Psychogenic

  21. History takingAbdominal gas • Belching, bloating (meteorism), flatulence • Causes • Aerophagia (habitual, poor dentition, inadequate chewing, rapid eating) • GI motor dysfunction or obstruction • Malabsorption, maldigestion • Bacterial overgrowth

  22. History takingBowel movement Factors: frequency, volume, fluidity, colour, associated sensations, change in bowel habits, stool calibre • Diarrhea > 300 g of stool/day more than 3 loose or watery stools/day • Constipation two or less stools/week • Incontinence

  23. History takingBowel movement • Stool alterations • colour -hypocholic, acholic - pleiochromic - bloody • Content - mucus - blood - fat - steatorrhea - undigested proteins - creatorrhea

  24. History takingBowel movement • Mechanisms of diarrhea • pathological motility • increased bowel permeability • decreased absorption • intraluminal osmotic factors

  25. History takingBowel movement • Constipation • Chronic or recent onset • Causes • Decreased fluid and/or food intake • Functional (irritable bowel syndrome) • Medications • Hypothyroidism • Fecal impaction • Rectal or colon cancer • Chronic debilitating disease

  26. History takingGI bleeding • Classification • Hematemesis - fresh blood - coffee ground • Melena - black • Hematochezia - blood on the stool - blood mixed with the stool • Occult bleeding

  27. History takingCauses of hematemesis Fresh blood • esophageal varices • Mallory-Weiss tear • gross (arterial) bleeding from ulcer Coffee ground-coloured matter • ulcer, erosion • gastro-oesophageal reflux disease • NSAID gastropathy • neoplasms • portal hypertensive gastropathy

  28. History takingCauses of GI bleeding • Melena • All the causes of upper GI bleeding Sometimes from the right colon or diverticula • Hematochezia • Rectal diseases (hemorrhoids, fissuras, neoplasms, polyps) • Colonic diseases (neoplasms, polyps, diverticula, agiodysplasias, colitides, IBD) • Rarely from the upper GI (massive bleeding) maroon-coloured stool

  29. History takingJaundice • Observe it in bright, natural light • First time you can observe on the sclerae • In cases of dark-coloured skin: observe: sclerae, under the tongue, palms soles, abdomen • Search for additional symptoms: generalised excoriations due to scratching

  30. History takingCauses of jaundice • Prehepatic: overproduction of bilirubin (hemolysis, ineffective erythropoiesis) • Hepatic: - problems of uptake of bilirubin - problems of conjugation of bilirubin - problems of excretion of bilirubin from the liver cell • Posthepatic: bile duct obstruction - cholestatic jaundice

  31. History takingJaundice • Important anamnestic factors • Colour of the skin: overproduction: lemon-like obstructive: dark-yellow, greenish • Colour of the stool: overproduction: dark, greenish (pleiochromic) obstructive: hypocholic, acholic • Colour of the urine: overproduction: cherry-red obstructive: dark, brown • Associated symptoms: anemia, pain, fever, hepatomegaly, splenomegaly, ascites

  32. Physical examination of the abdomen1.Inspection 2.Auscultation3.Percussion4. Palpation

  33. Position of the patient

  34. Physical examinationInspection • Configurations of the abdomen in the level or above or below the chest apple-type : visceral obesity - cardiovascular risk pear-type : gluteal obesity • Abdominal skin • striae : white, livid (pink) • hernias • veins : caput Medusae • visible peristalsis • visible pulsations • scars

  35. Generalised Obesity Pregnancy Ascites Bowel obstruction - ileus Big ovarian cyst Peritonitis Localised Hepatomegaly Splenomegaly Polycystic kidney Gastric distension Inflammatory mass Tumor Obstructed bladder Hernia Physical examinationAbdominal distension

  36. Physical examinationAuscultation • Bowel sounds • above the umbilicus or in the RUQ • normal: 5-35/min, clicks and gurgles • altered: absent: paralytic ileus hyperperistalsis: diarrhea, mechanical bowel obstruction • Bruits • arterial aortic, renal, iliac arteries • venous hum portal hypertension • Friction rubs spleen, liver, peritonitis • Succussion splashnormal: above the stomach pathologic: bowel obstruction

  37. Physical examinationPercussion • Meteorism • Liver span midclavicular line: 6-12 cm midsternal line: 4-8 cm • Splenic dullnessnorm: in the midaxillary line pathological:dullness in the ant. axillary line during inspiration • Liver or/and splenic dullness absent: perforation • Ascites shifting dullness

  38. Ascites shifting dullness

  39. Physical examinationPalpation • Position of the patient • Warm hands, short fingernails • Approach slowly, avoid quick movements • Exemine tender areas at last • Watch the patient’s face

  40. Physical examinationPalpation 1. Light palpation a. muscular resistance - guarding b. alterations in the abdominal wall

  41. Physical examinationPalpation 2.Deep palpation a. assessing abdominal masses b. assessing abdominal tenderness

  42. Physical examinationPalpation • Characteristics of an abdominal mass 1. location 2. size 3. shape 4. consistency 5. surface 6. tenderness 7. movable or fixed 8. shifting by respiration

  43. Physical examinationPalpation of the liver and spleen • Characteristics: 1. size 2. surface 3. edge 4. consistency 5. tenderness

  44. Palpation of the spleen • 1. supine position • 2. right lateral position

  45. Physical examinationPalpation of the gallbladder • Hydrops vesicae felleae Curvoisier’s sign - painless enlargement of the gallbladder due to cancer of the head of the pancreas Murphy’s sign - RUQ pain aggravated by inspiration - acute cholecystitis

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