Common Symptoms And Signs Of Gi

The gastrointestinal system Raed Alsulaiman,MD Assist.Prof.King Faisal University Consultant Gastroenterologist Department of medicine King Fahad Hospital University

The gastrointestinal history presenting symptoms Abdominal pain Appetite and/or weight change Nausea and/or vomiting Waterbrash Dysphagia Disturbed defecation

Bleeding Jaundice Dark urine,pale stool Abdominal swelling Pruritis Fever

Abdominal pain Three broad categories 1.     

Visceral pain: when hollow abdominal organs distended or stretched Difficult to localize Palpable near the midline Varies in character: burning, cramping,or aching If severe may be associated with sweating,pallor,nausea,vomiting and restlessness

Visceral pain

Abdominal pain Parietal pain Originates in the parietal peritoneum Caused by inflammation More severe, steady aching pain and more localized  Aggravated by movement and coughing  Patient prefer to lie still  Example :appendicitis 2.   

Abdominal pain 3.      

Referred pain Felt in more distant sites Usually well localized Pain my be referred to the abdomen from the chest,spine ,or pelvis Duodenal or pancreatic …..back Biliary tree…….right shoulder Pleurisy or MI….. Upper abdomen

Abdominal pain analysis 1. 2. 3. 4. 5. 6. 7. 8.

Character: colicky ,burning,steady Frequency Duration Site Radiation Severity Aggravating and relieving factors Associated symptoms

Peptic ulcer Cancer of the stomach Acute pancreatitis Chronic pancreatitis Pancreatic ca Biliary colic Acute cholecystits Acute diverticulitis Acute appendicitis Acute intestinal obstruction Mesentric ischemia

Appetite or weight change Anorexia: loss of appetite Anorexia and weight loss :malignancy or depression Weight loss and increased appetite: malabsorption,hypermetabolic state Anorexia and weight gain: hypothyroidism Increased appetite and weight gain: cushing’s syndrome,hypoglycemia

Nausea and vomiting Retching /vomiting/regurgitation Color ? Clear/mucoid/yellowish/blood Smell? Fecal odor Timing of vomiting? How much? Tea spoon,cupful Complication of vomiting  Aspiration  Dehydration

Nausea and vomiting causes Gastrointestinal disrorders Pregnancy Diabetic ketoacidosis Adrenal insufficiency Uremia Hypercalcemia Liver disease Drugs Induced but without anorexia:anorexia/bulemia nervosa

Heartburn waterbrash Sense of burning or warmth that is retrosternal and may radiate from the epigastrium to the neck It originate in esophagus It suggests gastric acid reflux into the esiophagus : GERD ,often precipitated by a heavy meal ,lying down,or bending forward Should be differentiated from pain of coronary artery disease

Dysphagia:difficulty swallowing Solid? liquid? Difficulty initiating swallowing? Oropharyngeal dysphagia Intermittent ? Progressive? Location? Pointing to the throat not specific ,pointing to the chest suggests esophageal disorder

Causes of dysphagia •      • 

Mechanical obstruction Intrinsin(within esophagus) Esophageal stricture Esophageal ca Pharyngeal web Lower esophageal ring Foreign body Extrinsic (outside esophagus) Goiter /mediastinal tumor

Neuromuscular  Achalasia  Diffuse esophageal spasm  Scelroderma  Myasthenia gravis  Myotonia dystrophica  Bulbar/pseudobulbar pulsy

Odynophagia :painful swallowing It occurs with any sever inflammatory process involving the esophagus Infectious esophagitis Peptic ulceration of esophagus Caustic damage of esophagus Esophageal perforation

Diarrhea

   

Frequency/consistency Acute , chronic or recurrent Descriptive terms: are the stools greasy or oily? Frothy? foul smelling? Floating on the surface or difficult to flush? Accompanying by mucus ,pus ,or blood?

Nocturnal diarrhoea suggests an organic cause Aggravating :diet Tenesmus:intense urge with straining but little or no result New travel?dugs? Family history Associated symptoms

Diarrhea 1.

Secretory diarrhoea

2.

Osmotic diarrhoea

3.

Abnormal intestinal motility

4.

Exudative diarrhoea

5.

Malabsorption

Constipation • • • • • •

What the patient means? Decrease in frequency? Hard or painful stool? Need to strain hard? Sense of incomplete defecation? Shape of stool ? Pencil-like stool seen in sigmoid ca Obstipation: in intestinal obstruction

Constipation causes

    

Life activities and habit Irritable bowel syndrome Mechanical obstruction: Rectal or sigmoid ca Fecal impaction Painful anal lesion Drugs Metabolic /neurological disorder

GI bleeding Hematemesis  Coffee-ground or red blood Melena  Black ,tarry stool  At least 60 ml of blood in GI Hematochezia  Indicate lower GI or massive upper GI bleeding

Jaundice/icterus

   

Yellow discoloration of the skin and sclera Mechanisms: Increased production of bilirubin Decreases uptake of bilirubin by the hepatocytes Decreased the ability of the liver to conjugate bilirubin Decreased excretion of bilirubin

Jaundice/icterus Color of urine? Color of the stool ? Acholic stool Skin itch ;pruritus? Abdominal pain? Recurrent? Risk factors for liver disease?  Hepatitis  Alcholic  Drugs  Hereditary

Abdominal distension Fat Fluid Fetus Flatus Faces ‘filthy, big tumor

Past history Surgical procedure History of PUD or IBD Drug history:  NSAID /aspirin  Paracetamol overdose  Halothane/phenytoin/cholthiazide  Rifampicine,sulpha drugs  Anabolic steroid

Social history Occupation Recent travel Alchol history Contact with jaundiced patients Sexual history Any injections(IV drug abuse ,tattooing)

Family history Bowel cancer IBD Splenectomy,anemia ,jaundice Liver disease

The gastrointestinal system examination Raed Alsulaiman,MD Assist.Prof.King Faisal University Consultant Gastroenterologist Department of medicine King Fahad Hospital University

Sequence of examination General appearance Vital signs Hand Upper arm/lower arm Head and neck Chest/heart

Abdomen /genitalia

General appearance The physical attitude :  Peritonitis: lie still  Abdominal colic: restless and rolling in bed  Congestive heart failure: orthopnic  Confused: hepatic encephalopathy

General appearance nutrition state Physique:  Appearance consistent with patient age  Thin / obese  Malnourished:  Presence and distribution of body fat  The muscle bulk  The presence of oedema

Assessment of nutritional state malnutrition Wasting of temporalis muscle Dry cracked skin Loss of scalp and body hair Poor wound heeling Wasted limb muscle Hyporeflexia Atrophy of subcutaneous fat

Assessment of nutritional state • • • •

Skin fold thickness Biceps Triceps: most common site Infra-scapular Supra-iliac region

Standard

80%

60%

Adult male 12.5

10

7.5

Adult female16.5

13

10

Nutrtional state

Moderate dipletion

Severe depletion

Normal nutrition

Assessment of nutritional state Body mass index (BMI)

Normal BMI=18-25 Overweight =25-29.9 Obesity>30 Morbid obesity>40 BMI<18 require nutritional advice

BMI= weight(Kg)/height(m)2

General appearance SKIN pallor Site:  Skin  Mucous membrane  Mouth  Conjunctiva

Cause  Severe anemia  Shock  Hypopituitarism  Person with thick or opaque skin

General appearance SKIN Jaundice in natural daylight Site  Skin  Sclera  Hard palate Cause • Hypebilirubinemia •

Conjugated

unconjugated

General appearance SKIN Pigmentation  Chronic liver disease

 Malabsorbtion

celiac disease Dermatitis herpitiformis

General appearance SKIN :

Acanthosis Nigricans

:Telangictasia

General appearance The hands/feet

Leukonychia

Clubbing

Palmar erythema

Clubbing

General appearance The hands/feet

Bruising Petechiae

Dupuytern’ contracture

General appearance Muscle wasting Spider nevi D.Dx : Venous star hereditary telengictasia

General appearance The face Eyes Kayser-Fleisher rings  Iritis

Xanthelasma

Parotid

General appearance The face The mouth  The teeth and breath Causes of fetor Faulty oral hygiene Causes of gum hypertrophy

Fetor hepaticus

Phynetoin

Ketosis

Pregnancy

Uremia

Scurvy

Alchol

Ginigivitis Leukaemia(monocytic

Paraldehyde Putrid(chest infection) Cigarettes

General appearance The face The mouth

The Tongue

Causes of pigmented lesions in the mouth

Coating over the tongue: thickened epi with bacterial debris and food particle

Heavy metals

Lingua nigra(black tongue):elongation of papillae over the posterior part

Drugs:antimalaria Addison’s disease Peutz-Jeghers syndrome Malignant melanoma

Geograpgic tongue:can be a sign of Riboflavin deficiency Leukoplakia :premalignant .?Sore teeth,smoking,spirits,sepsis ,syphilis Glositis :smooth tongue.Deficincy of iron,folate and B12 Macroglossia:Down’s syndrome acromegaly,amyloid,tumor

General appearance The face Cause of mouth ulcers 1. 2. 3. 4. 5. 6. 7.

Aphthous Drugs (gold,steroid) Trauma Gastrointestinal disease :CD,UC Rheumatological disease: Behcet’s disease Erythema multiforme Infection: viral-herpes zoster ,Herpes simplex Bacterial: Syphylis

General appearance Neck and chest Cervical lymph node : left suraclavicular lymph node with gastric ca (Troisier’s sign) Gynaecomastia

Spider nevi Campbell de Morgan spots

Physical Exam

Physical Exam

The abdomen Good light Relaxed patient Full exposure: from above the xiphoid process to the symphysis pubis The groin should be visible The genitalia should remain draped

Techniques of examination Check that the patient has an empty bladder Supine position, with a pillow under the head and perhaps another under the knees Keep the arms at the sides Before you begin palpation ask the patient to point any area of pain Warm your hands and stethoscope Watch the patient face for discomfort

Techniques of examination Inspection

Palpation

Light palpation Percussion Deep palpation Organ palpation Palpation of groin

Auscultation

Abdominal areas

Abdominal areas

Inspection

Inspection

    

Lay the subject supine General inspection of the abdomen symmetry of its shape the presence of markings and scars. the shape (contour) movement of the abdomen. Inspect the groin bilaterally and check for cough impulse

Inspection normal findings Skin surface Free of abnormal discoloration, new growth, striae, surgical scars, or prominent veins; Seborrhoeic warts and hemangiomas (Campbell del Morgan spots) may be normal findings in geriatric patients; Umbilicus is sunken

Inspection normal findings Shape Symmetrical in shape Scaphoid or flat in young patients of normal weight slightly full but not distended in older age group due to poor muscle tone or in subjects who are mildly overweight

Inspection normal findings Movement Rises and falls rhythmically with inspiration and expiration respectively Pulsation of the abdominal aorta may be seen in the epigastrium of a slender person Cough impulse No cough impulse should be seen along the inguinal canals

Inspection abnormal findings

1. 2. 1. 2. 3.

Skin surface Striae :recent weight loss except in postpartum females Scars :previous surgical operations Prominent veins inferior cava obstruction portal hypertension; Umbilicus is flat or protruding Umbilical hernia Abnormal intra-abdominal fluid collection (e.g., ascites) or masses. Tumor

Abdominal scars

Abdominal veins

Abnormal findings Shape or contour A sunken abdomen with prominent ribs and bony pelvic landmarks is seen in emaciated patients Symmetrical distension is seen when intra-abdominal content is increased (adipose tissue in obesity, gravid uterus, increased bowel contents like gas or fluid in bowel obstruction, peritoneal fluid in ascites); Gross enlargement of the liver may be seen as a bulge in the right upper quadrant; Gross enlargement of the spleen may be seen as a bulge in the left upper quadrant; Enlarged kidneys may be seen as bulges in the lumbar regions in rare occasions; An enlarged urinary bladder or uterus may be seen as a central rounded suprapubic swelling rising out of the pelvis

Abnormal findings Movement Abdominal movement associated with respiration may be minimal or absent in peritonitis; Gastric peristalsis may be seen across the upper abdomen from left to right in gastric outlet obstruction; In bowel obstruction, vigorous small intestinal peristalsis may be seen in the center of the abdomen Cough impulse  Inguinal hernia

Palpation

Palpation 1. 2. 3.

Light palpation Abdominal muscle tone Tenderness rebound tenderness.. When muscle tone is increased, there is resistance to depression of the abdominal wall by the palpating hand; it commonly accompanies the presence of tenderness. Tenderness is a sign that the peritoneum under the abdominal wall or the underlying organ is inflamed. Rebound tenderness is pain elicited when pressure applied to the abdomen wall by the palpating hand is suddenly released. It is a sign that the underlying peritoneum is inflamed.

Palpation Light palpation The normal abdomen feels soft to palpation; There should be no tenderness or rebound tenderness

Palpation Light palpation: abnormal findings Failure by the patient to relax.  Ask the patient to take slow deep breaths can also help. Increased in muscle tone, tenderness, and rebound tenderness are indications of organic disease. Guarding : voluntary or involuntary Rigidity: involuntary

Palpation Deep palpation The purpose of deep palpation is to feel for organs in the depth of the abdominal cavity.

Palpation In slender patients with a soft abdomen the following may be palpable: the caecum in the right iliac region the transverse colon in the epigastrium, the colon in the left iliac region if they are filled with feces the pulse of the aorta in the epigastrium.

Deep palpation ;abnormal findings Lesions on the abdominal wall can be distinguished from those inside the abdomen by asking the patient to tighten his abdominal muscles (e.g., by asking the patient to lift his head off the pillow and look at his toes): those on the abdominal wall will remain palpable while intraabdominal lesions are not.

Description of abdominal mass Location (in the wall of or inside the abdomen; also its position according to the quadrants or regions of the abdomen and its relation to other organs). Shape (round, oval, irregular, etc). Size (in terms of diameters in at least 2 of the 3 dimensions). Consistency (hard, firm, rubbery, soft, fluctuant, indentable, pulsating). Surface texture (smooth, nodular, irregular, etc). Mobility (free or fixed to adjacent tissue, movement in relation to respiration). Tenderness (tender or non-tender). Pulsation

If mass is pulsatile ? If it is expansile 1. aortic aneurysm 2. a fluid filled cyst on top of the aorta

it is not expansile, the palpated mass is on top of the aorta.

Liver palpation

Liver palpation

      

Start in the right iliac fossa If liver edge is felt describe: Size Surfce Edge Consistency Tender Pulsatile ?bruit

Liver palpation Normal findings The liver can descend for up to 3 cm on deep inspiration and its edge can be, though not always, palpable just below the right costal margin without being enlarged in many normal subjects. The normal liver edge is sharp, smooth, soft, and flexible. The normal gallbladder is not palpable

Differential diagnosis in Liver palpation Hepatomegaly Massive Moderate Mild Metastasis Haemochrmatosis Hepatitis Haematological Alcholic liver Biliary obstruction disease with fatty disease(CLL,lymphom Hydatid disease a) infiltration HIV Fatty liver in DM Myeloproliferative The massive and Infiltration e.g disease moderate causes amyloid Right heart failure the massive causes Hepatocellular ca

Firm and irregular

Cirrhosis

Metastatic disease Hydatid disease granuloma

Tender liver

Hepatitis

Right heart failure

Hepatic abcess HCC

Pulsatile live

Tricuspid regurgitation

HCC

Vascular abnormalities

Gallbladder courvoisier’s low: Palpable gallbladder in the presence of obstructive jaundice is due to carcinoma of the head of pancrease until proven otherwise. . Murphy’s sign : inspiratory effort may be arrested abruptly due to pain. It indicates acute cholecystitis

With jaundice 1. 2.

Carcinoma of the head of pancreas Apulla of vater Ca

Without jaundice 1. 2. 3.

Mucocele or empyema Gallbladder ca Acute cholecystitis

Spleen palpation

Spleen palpation The normal spleen in a healthy subject is not palpable If spleen is not palpable in supine position ,ask the patient to turn into right lateral position and palpate for the spleen (splenomegaly) it does not appear subcostally until it is 2 times normal size.

Splenomegaly Splenomegaly Massive

Moderate

CML Portal hypertension Myelofibrosis Lymphoma Malaria Leukemia Kala azar Thalassemia storage disease Primary lymphoma of spleen

Small Haemolytic anemia Megaloblastic anemia Infection: Viral(hepatitis) Bacteria(SBE) Connective tissue disease: e.g rheumatoid arthritis,SLE ,polyarteritis nodosa Infiltartion: Amyloid,sarcoid

Kidney palpation Bimanual technique Ballottement technique

Right kidney

Right kidney The lower pole of the right kidney may be felt Pounding on the costo-vertebral angle should not cause pain. Abnormal findings Features of any abnormal mass should be described: location, shape, size, surface texture, consistency, mobility, and tenderness. Tenderness at the costo-vertebral angle means infection or inflammation of the kidney

Spleen or left kidney? spleen

Kidney

no palpable upper border can’t get above it

Palpable upper border can get above it

One or two notch

No notch

Moves inferomedially with inspiration

Moves inferiorly with inspiration

Nor ballotable

Ballotable

Dull percussion note over the spleen

Resonant percussion note over the kidney

Friction rub may be occasionally heard Friction rub never heard

The aorta Upper abdomen left to the midline Diameter should not exceed 3.0cm

Palpation of the groins femoral pulses , abnormal lymph nodes and hernias Stand to one side of the subject and palpate the right and left femoral artery, which lies just below the inguinal ligament mid-way between the anterior superior iliac spine and the pubic symphysis. Feeling with the fingers, palpate along the femoral artery and the inguinal canal on both sides for abnormal or enlarged lymph nodes. Place the palmar surface of the fingers of one hand over the inguinal canal on one side and the same with your other hand on the other side. Do not cross your arms. Check for expansile (cough) impulse in the inguinal canal while the subject coughs.

Percussion

Percussion Technique of percussion

Percussion of the abdomen 1. 2. 3. 4.

Percussion is used to: delineate the borders of the liver, the enlarged spleen, or other masses. to determine if abdominal distention is due to gas-filled bowels or accumulation of fluid (a condition called ascites). When percussion is practiced, always proceed from a tympanitic or resonant site towards a dull or flat site and position the middle finger that receives the strike parallel to the anticipated border and not perpendicular to it.

Liver percussion

Spleen percussion Traube’s space  Left costal margin, left 6th intercostals space and left midaxilary line

Spleen percussion Splenic percussion sign

Ascites Shifting dullness

Ascites Fluid thrill

Appendicitis Muscular rigidity Rebound tenderness Rovsing’s sign Referred rebound tenderness Psoas sign Acute cholecystitis Murphy’s sign

Auscultation 1. 2. 3.

bowel sounds produced by peristaltic activities Vascular sounds Friction rub

Auscultation Listen for bowel sounds for at least 30 seconds over the right lower quadrant succussion splash : splashing noise due to wave-like motion of fluid in an air-filled cavity Steady the diaphragm of the stethoscope over the right upper quadrant with one hand. Shake the abdomen from side to side vigorously at the same time with the other free hand and listen for splashing sound

Auscultation 1. 2.

3. 4.

Listen for bruits The abdominal aorta (A) at the epigastrium; The renal arteries (R) at the hypochondrium bilaterally or the costovertebral angle at the back bilaterally; The iliac arteries (I) in the center of each lower quadrant; The femoral arteries (F) just below the mid-point of the inguinal ligment bilaterally.

Normal findings Normal bowel sounds are intermittent and heard as bursts of continuous sound every 5 to 10 seconds. Succussion splash may be heard in normal subjects for up to 3 hours after a meal. No arterial bruit is heard in the normal abdomen. No venous hum is heard in the normal abdomen.

Abnormal findings Acute bowel obstruction, bowel sounds are exaggerated in intensity due to increase in peristaltic activity. (borborygmi) • Peritonitis bowel peristalsis stops (paralytic ileus) and the abdomen is silent. • Succussion splash heard in a subject more than 3 hours after a meal is a sign of gastric outlet obstruction.. Systolic bruit stenosis of the underlying artery. Venous hum is rarely heard. When present, it is a sign of venous collaterals developed secondary to portal hypertension (cruveilhier-Baumgarten syndrome)

Rectal examination         

Abdominal examination is not complete without the performance of rectal examination Rectal prolapse Fistula-in ano Skin tag Anal fissure Condylomata accuminata Thrombosed external haemorrhoid Anal ca Pruritus ani Excoriation from diarrhea

Rectal examination Palpate the anterior wall of rectum for prostate in male and cervix in female Tenderness :  Anal fissure  Ischciorectal abcess  Recently thrombosed pile  Proctitis  Anal ulcer  Always inspect finger for blood

To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all