Internal Diagnosis 2 Gi

Internal Diagnosis 2 GI/GU 1. Picture of left lower leg: Pitting edema, pale, toe tag-deceased/amputated (not likely-no blood): skin tight & shiny = edema (waxy look due to no hair) + no visible medial malleolus: DDX- CHF, death, renal failure, pretibial myxedema = hypothyroidism. a. Dependant edema: Ambulatory = lower extremity: Bedfast = sacral edema 2. Picture of both hands of a black, male, middle aged, vetiligo spots on right hand (depigmentation), hospital band on; Hands asymmetrical (photo?); severe clubbing of all digits worse on right: DDX: COPD, cystic fibrosis, CHF, chest/belly cancer #1 on list due to severity; vitamin deficiency, nerve damage. a. Periosteal reaction in long bones; nails, soft tissue, & bone involved. 3. Red Flags in assessment: a. Mechanical if some position of comfort can be reached b. Somatic if NO position of comfort can be reached c. Constant pain without trauma! 4. Picture of WF middle aged, married, gavid, slightly obese, with large mass in LUQ of abdomen: Is an incisional hernia from cholecystectomy (buttonhole puncture wound): asymptomatic = do nothing. a. Auscultate for 1st: borborygmus (plural: borborygmi) = bowel sounds b. Palpate for pulses: R/O AAA: DDX: Spleenomegaly & cancer c. Palpate for tenderness, hardness, pliability d. Valsalva will increase size e. Percussion: tympanic or Hyper-resonant f. A partial sit up will tighten abs: decrease size of mass = intra abdominal: Increase = abdomen wall g. M/C surgeries: GB, Hyst, tonsils, vasectomy, mammoplasty. 5. History • AMPLE o Allergies: PCN, Sulfa, iodine, milk, nuts m/c: Drugs & foods, how long have had? o Medications – for what condition, how long, side effects o Past Medical History o Last Meal (meal for GI/GU testing) / LMP (1st day of onset of bleeding) o Events of present illness • OPPQRST o Onset: Insidious is always bad: trauma is what we want to hear! o Provocative: what makes worse? Ask about ETOH/drugs for GI. o Palliative: what makes better? o Quality – character and type: scales o Radiation (nerve compression) / Region vs Referred- visceral. o Setting: Tasks, positions of comfort o Timing: How long? Day vs night? • HISTORY o Hospitalization: How many? For what? Outcome? o Injuries: trauma-what king? DX? What was done? Outcome-how r u now? o Sugar diabetes: Always include in DDX o Tumors: Benign or malignant? Cell type? What done? Outcome? M/C chiro sees = Lipoma on back o Operations: When & why & outcome? o Review of systems: very important to see if patient wrote all down or “forgot” o Youth Dz: mumps, measles, Ruebella, chicken pox, polio 5. Physical Exam: Do in this order to avoid disturbing organs till necessary & change bowel tone. a. Inspection: symmetry, size & shape: Abdomen is hourglass shaped: no matter what size, follows contours of body. Lumps, bumps, scars, ecchymosis (bruising=bleeding): i. investigate asymmetry (eg hernia) ii. ascites → m/c reason for ↑ size (in relation to rest of body) iii. truncal obesity → Cushing’s

iv. stomach shape → should be flat (lateral), should be hour glass (A-P) v. tangential light → outlines shape withshadows vi. m/c scars ; Cesarean – usually low (bikini line), Cholecystectomy ( usually laparoscopic), Appendectomy vii. Other causes of scars: Closed colostomy, Striae, Splenectomy, Liposuction, GSW, Stab wound b. Auscultation: of abdomen all quads o Borborygmus → bowel sounds [5-35 (N)]  High pitched → use diaphragm o Appreciate change in pitch → eg.↑ pitch means bowels are working hard to get past obstruction o May also ↑ or ↓ in frequency  No bowel sounds → obstruction (late)  ↑ bowel sounds → early obstruction o Late obstruction → vomit o Adynamic bowel → due to blunt impact or post operative → no bowel sounds  Paralytic lieus –non-mechanical secondary to surgery or MVA  Obstruction o Bruits → swishing noise: Stenotic sounds like murmur  Due to turbulence of blood, narrowing (speeds) or expanding (slows) of arterial wall. i. m/c infrarenal AAA, renal artery stenosis c. Percussion: o Liver, spleen, diaphragmatic excursion o LUQ  Tympanic → air in stomach  Dull → eaten recently o Spleen → dull: If felt = abnormal o Liver → dull: if inferior border is felt probably enlarged & firm o rest of abdomen → resonance o bowel obstruction → dull over obstruction  tympani above obstruction i. resonance distal to obstruction d. Palpation: • Organomegaly • Aneurysms • Mass → where is it? Size? Borders? Pulsate? Pain? Firm/soft? Refer pain? Mobile? Superficial/deep? • Palpation start in non-tender quadrant, diagonal to area of pain • Superficial → palpate in abdominal wall • Deep → palpate in abdomen • If mass disappears withabdominal contraction → intraabdominal mass • Mass accentuation withabdominal contraction → abdominal wall mass • Usually better if mass is mobile o Benign → only in host tissue o Malignant → invade surrounding tissue, more inflammation, causing CT formation = less mobile • Done after auscultation so as not to influence bowel sounds • Palpation for pain • If ticklish use pt’s hand • What type of pain

o Sharp, dull, cramping Decrescendo, crescendo pain → luminal organs usually are the cause Organomegaly o Usually liver/ spleen o Liver RUQ: If inferior border felt is possibly enlarged  Detoxifies  Hormones  Over 1000 functions o Spleen LUQ: if felt is abnormal  Should not be palpable (unless extremely thin) o Hepatosplenomegaly  usually liver disease  blood forming product disease’s  o m/c aneurysm → AAA (infrarenal) LUQ  most are saccular rather than dissecting  palpate with 2 fingers – one on either side of aorta • separation of fingers on pulsation shows lateral dilation = AAA pass • also palpate with 4 fingers on top of aorta • thinner pt’s = more pronounced pulsation  not likely to rupture AAA on exam • aorta N diameter max = 3.5 cm  AAA → produces non-mechanical back pain • Pts are ortho, neuro, and mechanically intact o Abdominal rigidity – muscle tension to point “hard as desktop” 6. Abd Exam Tips • Comfortable temp • Gowned with ab & groin exposed: Genitalia draped • Empty bladder • Start in non-tender quad & end in painful one • Strong/firm touch if ticklish (your hand over patients till adjust then Dr. hand only) • Normal kidney not palpable: lower pole may be on thin patients • M/c cause of hepatomegaly → alcoholism: Normal liver palpated 8-12 cm @ MCL on right e. Abdominal Regions: i. 4 quadrants 1. Rt upper: Liver, GB, descending duodenum, head of pancreas, pyloric stomach, part of transverse colon & hepatic flexure, Rt kidney & renal artery, IVC 2. Lt upper: Spleen, tail of pancreas, Lt kidney & renal artery, left part of transverse colon & spleen flexture, Lt lobe of liver, Superior Mesenteric artery, cardiac stomach, aorta 3. Rt lower: Rt bladder, Rt ovary, iliem & jejunum, appendix, ascending colon, Inferior Rt kidney, vena cava, ilio cecal valve 4. Lt Lower: ascending colon, Lt kidney lower pole, sigmoid colon, aorta & bifurcation Lt iliac artery: uterus may refer pain here- is in suprapubic area ii. 9 Regions 1. R/L Hypochondriac: below ribs 2. Epigastric: Zyphoid area to hypochondriac 3 upper 3. R/L Lumbar 4. Periumbilical • •

5. R/L Pelvic: soft tissue of pelvis 3 lower 6. Suprapubic/Hypogastric: bladder area f. Abdominal Exam Tests: i. Rebound tenderness: press on any quad away from painful quad & release fast = pain ii. Peritonitis (Rovsing’s sign), push in quadrant with no pain, but pain is felt in different quadrant usually diagonally across. Press LUQ- Pain RLQ = appendicitis: Late sign iii. PN with recoil Palpation iv. CVA Tenderness (Costal Vertebral Angle, on back where the 10-12th rib meets spine) 1. Kidney disease vs quadratus lumborum spasm= sharp pain in flank after “punch” 2. AKA: Kidney Punch: sharp rap at CV angle; R/O stones do UA 3. + Murphy’s punch test is M/C renal so R/O 1st. v. Shifting Dullness: fluid test: Lay on one side for minutes & percuss then turn & percuss 1. Ascites: Percussion for dullness 2. Fluid shifts in different positions vi. Psoas Sign: Retrocecal appendix placement dx: swollen & rubs psoas with flexion 1. Appendicitis & position test for surgeon 2. Resisted Rt hip flexion vii. Obturator sign: Same as above for psoas 1. Appendicitis 2. Resisted internal rt hip rotation g. DX Imaging: BaSO4 + CO2 = double contrast to trace walls: the air forces the Ba into walls • Barium swallow: UGI: looks at EGD: thick to check swallow EGD – Esophagus gastroduodenal • Barium enema: LGI: limit air in = painful gut = distention • CT scan with contrast: for seeing lymphnodes, tumors: iodine used for vessels or barium for outline: good for hollow organs • MRI scan with contrast: not good for hollow organs • Endoscopy: direct viewing of GIT & capable of biopsy: Best procedure: Biggest problem is operator errorscope must be turned to view all areas (360 degrees) or can miss dx findings. h. Common GI S&S: abdominal distension, pain, anorexia, belching, bloating, farting, bleeding, constipation/diarrhea, N/V, heartburn/indigestion/dyspepsia, hepatomegaly/spleenomegaly, hernias, hiccoughs, jaundice, rectal pain/itch a. Abdominal distension: 2 main causes: Usually fluid or gas i. Mechanical Obstruction 1. Neoplasm a. Intraluminal: m/c colon cancer-distal no n/v: starts with normal BMs constipation diarrhea (influx of H2O) constipation: If in inferior small bowel-n/v. Early have hyper BS-less distension; Late = absent BS listen 1 min per quad to be sure are none present: Seen on x-ray. b. Extraluminal 2. Post-operative adhesions: adynamic ileus: Uterine lyomyoma- a fibroid, benign & common: seen on lumbar spine films: can calcify: look like popcorn on x-ray: can be massive: 350 pounds= constipation, frequent urination; menses stop-they think they are pregnant 3. Abcess: extraluminal 4. Pregnancy- constipation 5. Hernias 6. Volvulus: twisting of bowel: secondary to adhesions: m/c sigmoid & cecum 7. Intusseception: telescoping of bowel into self- creates a ball of obstruction. ii. Non-Mechanical Obstruction 1. Ascites: m/c of all path: fluid in perineal cavity 2. Excess gas: m/c non-path 3. Trauma: blunt impact top abd: seatbelt in MVA

4. Infection 5. Peritonitis: Leaks perineal fluid into cavity: Perineal cavity= triangle between xyphoid process-sigmoid on left-cecum on right: circle around this triangle = retroperineal. 6. Abdominal Pain Patterns: m/c complaint a. Diffuse: Early appendicitis, AAA, IBD (depends on where), Peritonitis, trauma, obstruction i. Visceral pain ii. Organ involvement b. Focal: i. Parietal perineum pain: Know appendicitis ii. Organ distension: Hepatomegaly from hepatitis: capsule stretch receptors excite nocieceptor for local pain. iii. Peritonitis: diffuse infection-diffuse pain iv. Kidney – back pain ipsilateral 7. Types of Abdominal Pain: a. Burning: epigastric usually or chest = R/O MI i. PUD (Peptic ulcer Disease) & GERD (GastroEsphosogeal Reflux Disease) b. Cramping: usually from organ distension- local i. Billiary colic: Gallbadder- stones or spasm ii. IBD: Inflammatory Bowel Disease: Crohn’s, UC (ulcerative colitis) iii. IBS: Irritable Bowel Syndrome: Intermittent severe diarrhea attacks iv. Mesenteric ischemia: most painful, less blood flow with necrosis c. Colicky: Crescendo/Decrescendo: Builds with peristaltic waves nearing obstruction & subsides as wave passes. i. Renal stones: Ureters & urethra ii. Biliary colic: Gall stones iii. Appendicitis d. Achy: can mean anything i. Constipation: M/C ii. Appendicitis iii. AAA (saccular) e. Knife-clasp: usually very serious: fetal position for comfort usually i. AAA (dissecting/saccular rupture) ii. Pancreatitis f. Sudden Onset: SCARY! i. Perforation ii. Obstruction iii. Pancreatitis iv. Ruptured Ectopic pregnancy 8. Epigastric Pain: Mid upper abdomen a. PUD – classic b. Gallbladder disease c. Liver disease: M/C cause Alcoholic Hepatitis  cirrhosisd. Cardiac disease e. Pancreatitis: physiological: m/c idiopathic: ETOH & obstruction = digests self = pain! 9. RUQ pain: a. Biliary tree disease: GB duct stones: cholecystdocolisthiasis b. PUD: duodenal ulcer m/c c. Pancreatitis d. Renal disease: m/c stones, second m/c pyleonephritis, 3rd glomerulonephritis e. Cardiopulmonary disease: referred pain 10. LUQ pain: PUD, Pancreatitis, renal disease, cardiopulmonary- referred a. Spleenic disease: m/c ETOH

b. Gastritis: m/c = catch all term for lazy doctors 11. RLQ pain: a. Late appendicitis b. Crohn’s m/c: regional enteritis: mouth to rectum: skip lesions c. Obstructions: volvulus, obstruction d. Reproductive disease: PID, endometriosis e. AAA: left of midline 12. LLQ pain: M/C Diverticulosis/it is; obstruction, UC, reproductive, AAA- infrarenal m/c. 13. Periumbillical pain: a. Obstruction of small bowel b. early appendicitis c. AAA d. Mesenteric thrombosis- more painful than most e. Pancreatitis- local. 14. Acute Appendicitis: M/C cause of organic abdominal pain: 17% of all abd pain treated a. Late- acute abdomen: rigid abdomen- rock hard, diaphoretic, acute severe pain, ?fever, look ill, involuntary contraction of abdomen- rigid. b. Early -Guarding is early sign = voluntary protection of pain. 15. Intestinal Obstruction: Adhesions M/C 16. Urological: cystitis- Lower UTI: Quadratus lumborum spasm may mimic stone 17. Pancreatitis: chiropractor- may have LBP- knife in mid-to-lower thorax 18. AAA: LBP & belly pain: no position of comfort & usually can’t reproduce pain with orthopedic tests: a. May have LBP (Knife-like mid to lower thorax = Pancreatitis) (LBP & belly pain = AAA) b. Lateral lumbar pain: focal widening >3.5cm on lateral lumbar x-ray (25% less visible-looks smaller); may underestimate secondary to thrombus- uncalcified = can’t see on plain film- get scan: see 75-90% of mural calcifications c. 60 Y/O M:F 5:1; associated with atherosclerosis, secondary to inflammation = abnormal Homocystine  fat is laid down: B9, 200mg QD & more prn or B12 & B6 d. 90% Infrarenal, may extend to common iliac arteries i. CT: Perianeurysmal fibrosis (10%) around thrombus: cause left (m/c) ureteral obstruction ii. Ultrasouind 98% accurate in size iii. Angiography: mural thrombus in wall- if loose may obstruct lower iliac e. Complications: i. Rupture (25%) into retroperineal (m/c) usually left; some into GIT; some into IVC (A-V fistula). ii. Peripheralembolization (iliac) iii. Spontaneous occlusion of aorta: thrombus or spasm f. If aorta has atherosclerosis: check coronary arteries & do lipid profile g. Common in DM: Spleenic h. Suprarenal/infrarenal are harder to fix if in kidney i. Saccular AAA: m/c: fusiform or football shape: usually asymptomatic till rupture or start dissecting j. Dissecting AAA: walls of aorta pull apart by pressure of vasculations: tears in both directions i. Tertiary syphilis ii. Surgical emergency: fills walls with clots – exsanguination without seeing any blood iii. Tearing pain for 8-16 hours before death: if slow leak may last for days-months. k. S & S: Most are asymptomatic i. Pulsating sensation in abdomen ii. Abdominal pain (unchanged by position) iii. LBP (unchanged by position) iv. Bruit: low frequency (caused by dilation of wall) v. Radiating pain to legs vi. Cold legs: peripheral pulse loss vii. Shock: systolic B/P <90mmHg = no organ profusion:

1. Cold, sweaty (calmy), n/v, low B/P, high pulse & weak, high resp, syncope viii. Sudden death l. Imaging: Plain films, MRI/CT m. Treatment: Depends on size at diagnosis: i. 3.5-5 cm = careful observation if asymptomatic: DO NOT ADJUST ii. 5-7 cm: elective surgery (10% rupture) iii. >7 cm: mandatory surgery (25% rupture/6mos): 2 year prognosis iv. If symptomatic at any size: mandatory surgery v. Surgical procedures for AAA: 1. Open laparotomy: cut open & repair 2. Endoscopis stent placement: tube put inside of aorta 3. 50% of patients with rupture survive 19. Anorexia: Lack of appetite: Anything can cause: GI dz m/c a. Infection: Bacterial Enteritis- food poisoning: “Stomach Flu”: b. Neoplasm (m/c malignant) anywhere c. IBD: Inflammatory Bowel Dz: Crohn’s, UC d. Constipation: common- may be a reflex to stop input till output begins again e. GERD: reflux- pt fear f. PUD: Peptic Ulcecr Dz: depends on where lesion is: sometimes food helps pain g. Swallowing d/o: Esophagus h. Cachexia: wasting away i. DDX: cancer; liver dz-cirrhosis (m/c), hepatitis 20. Belching: retrograde reflux of air across vocal cords (sound) a. Aerophagia: swallowing air: m/c cause of belching & flatulence: some air is absorbed 21. Bloating: Lesser form of distension: PMS water gain, etc. a. Insoluble carbohydrate ingestion: fiber: bloat & belch-2nd m/c 22. Flatulence: Gas expelled via anus: odor dependant on foods eaten: egg yolks produce sulfur smell a. M/c gas is methane: flammable b. Malabsorption syndromes: bacteria produce c. Lactose intolerance- kids d. Diarrhea- hypermotility 23. GI bleeding: a. Upper GI: Mouth to Ligament of Trietz: Suspensory ligament of duo (holds “C” to wall-pancreas) i. Esophagus Varicies: M/C: dilated veins from Portal hypertension-m/c cause Cirrhotic Hepatitis: can erode & bleed. Present with: 1. Hematemesis: bright red blood (undigested) if acute & lots of it 2. Slow Chronic: small to moderate amount in stomach- denatures Hgb = coffee ground emesis = black/dark specks in emesis ii. Esophageal cancer (CA): 90% are malignant: some bleed from ulceration: hematemesis/coffee grounds. iii. Esophagitis: GERD-mechanical, toxic chemicals iv. PUD: 2nd M/C cause in mucosa v. Gastric CA: less in USA: vi. Hiatal Hernia: Stomach pushes up through diaphragm: 2 types 1. Sliding: G-S slide up to left mediastinum 2. Rolling: Paraesophageal: Esophagus in place & stomach rolls up into it & mediastinum: a. Paraesophageal hernias can be huge, with the entire stomach in the chest. Both the esophagogastric junction and the pylorus may be level with the diaphragm as the gastric fundus rotates upward into the left or right side of the chest. A large gas bubble can be seen on chest x-ray, and the diagnosis is confirmed by barium contrast studies.

b. Paraesophageal hernias can cause complete pyloric obstruction and gastric incarceration, strangulation, and perforation. Unless the patient is a poor surgical risk, these hernias should be repaired. 3. The diagnosis is based on barium contrast studies, endoscopy, and 24-hour esophageal pH monitoring. The differential diagnosis includes coronary artery disease, esophageal spasm, gallbladder disease, gastritis, peptic ulcer, and functional complaints for which no organic cause can be found. Symptoms that appear suddenly suggest malignant disease, not only of the esophagus but of any abdominal organ. Consequently, an abdominal rather than a thoracic approach is used for repair because an unexpected tumor may be found. 4. Asymptomatic hernias should not be repaired. Mild complaints are treated by conservative measures, including a bland diet, weight reduction, antacids, and nighttime elevation of the head and chest using several pillows or blocks under the bed supports. vi. Swallowing Hemoptysis (lung): b. Lower GI: Ligament of Trietz to anus i. Mesenteric Thrombosis: Most painful: Superior/Inferior/Celiac access or branches: 1. Bowel Necrosis from ischemic infarct = bleeding ii. Merckel’s Diverticulum: Remnant of embryological duct (Vitiline?) in distal ilium- creates an appendix, filled with GASTRIC mucosa, can be obstructed, ulcerate-bleed iii. Volvulus/intussecption: Twisting m/c cecum/sigmoid (infract necrosis bleed) iv. Colon CA: Not common to bleed, usually asymptomatic till obstruct or erode vasculature v. Colon Polyps: Blood streaked stools: adenomatosis (multiple growths in glandular tissue)rare bright red. vi. IBS: Crohn’s (little or none), UC: bright red blood per rectum (BRBPR) = Hematochezia (UC m/c) vs. Melana- black Tarry stools- lots of blood. vii. Diverticulosis/it is: Increased incidence with age: 1. Hemorrhoids: m/c left colon- BRBPR or streaked: dilated veins 2. Anal fissures: Cracks- IBD- many BMs/day chaffed cracks c. Tests: Stool for Guiaic: Occult blood smear: FOB testing: “Hemocult”, can be from anywhere, usually higher than rectum- need 3 to confirm diagnosis. 24. Constipation: less fecal output: hard, dry, pellets, painful. a. Impaction: fecal mass obstruction b. Poor fiber intake: bulk & holds water in GIT c. Poor water intake} both M/C causes d. Colon CA: obstruction e. IBD: alternating with diarrhea f. Psychiatric: afraid to let go? g. Medications: analgesics, parasympatholytic/sympathomimetic h. Hemorrhoids: hurts 25. Diarrhea: Increased fecal output volume: loose, watery a. Infection: M/C: viral gastroenteritis b. IBD: Inflammatory Bowel c. IBS: Irritable Bowel d. Stress e. Colon CA f. Psychiatric: anxiety g. Medications: Stimulants, Sympatholytic/parasympathomimetic 26. Nausea & Vomiting: causes pg 1106b, DDX 1201b: Hyperemesis gravidarum pg 442: a. Infectious gastroenteritis: FOOD POISONING-E. coli m/c:Viral/bacterial: (obstruction-esophageal, pyloric, intestinal- upper; metabolic-uremia, electrolyte abnormality, DKA, acidosis/alkalosis, DM ketoacidosis, thyrotoxicosis): Turtle/reptiles have salmonella

b. Pregnancy: 1st trimester, wt loss, fluid & electrolyte imbalances: DDX: Pancreatitis, cholecystitis, hepatitis, pyelonephritis: B1, B6, Phenergan, IV- TPN: not a psych problem. Smells, food: hormonal changes.2/3 of all preg, gone by 2nd trimester. c. Severe pain: MI, renal colic, blows to testicles/epigastrium); To avoid digestion! d. Cardiovascular disorders e. Medications: (NSAIDS, erythromycin, morphine, codeine, aminophilline, chemotherapies-cytotoxic agents, bromocriptine) (withdrawal from drugs, alcohol) (Reye’s syndrome, eye disorders, abdominal trauma) (Digitalis f. PUD: Pancreatitis, appendicitis, biliary colic, peritonitis, perforated bowel, diabetic gastroparesis) g. GI CA h. Psychiatric disorder: Bulimia, anorexia nervosa: (head trauma, middle ear, migraine, CNS CA), anxiety, stress.  Vomiting is controlled by a medullary center which receives input from four areas: 1. Afferent vagal and splanchnic fibers from the gastrointestinal viscera (Vagal = parasympathetic, Splanchnic = innervation of the GI tract) 2. The vestibular system 3. Higher central nervous system centers triggered by sights, smells or emotional experiences 4. The chemoreceptor trigger zone (in the area of postrema) which maybe stimulated by hypoxia and chemo toxins in the blood Nausea- feeling of impending vomiting:

 Complications of vomiting include:  Aspiration (aspiration pneumonia: aggressive sometimes lethal)  Malnutrition  Fluid & electrolyte imbalance  Gastroesophageal mucosal tear (Mallory-Weiss syndrome) – from prolonged wrenching  Post-emetic rupture of the esophagus (Boerhaave’s syndrome) – people w/ chronic esophageal conditions: scleroderma, Barrett’s, etc. Goes to the mediastinum --> leads to Mediastinitis