Transcript Tanfolyam
PropedeuticsGastroenterology 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 • Duodenal ulcer • Pancreatitis • Hepatitis, hepatic congestion • Colon cancer • Nephrolithiasis, hydronephrosis, pyelonephritis • Pulmonary causes • Diaphragmatic pain Epigastric • Peptic ulcer • Gastro-oesophageal reflux disease • Pancreatitis • Cholecystitis • Intestinal obstruction • Gastric cancer • Functional dyspepsia • Myocardial infarction • Abdominal angina Left upper quadrant (LUQ) • Colon cancer • Colitis, irritable colon syndrome • Pancreatitis, pancreatic cancer • Splenic causes • Nephrolithiasis, hydronephrosis, pyelonephritis • Pulmonary causes • Diaphragmatic Periumbilical • Enteritis • Appendicitis (early) • Pancreatitis, pancreatic cancer • Intestinal obstruction • Aortic aneurysm • Abdominal angina Lumbar • Kidney stone • Pyelonephritis • Perinephritic abscess • Colon cancer Right lower quadrant (RLQ) • • • • • Appendicitis Colon cancer Crohn’s disease Ureterolithiasis Salpingo-oophoritis (adnexitis) Hypogastric • • • • • Cystitis Salpingitis Ectopic pregnancy Prostatitis Colonic pain Left lower quadrant (LLQ) • • • • • Diverticulitis Colon cancer Ulcerative colitis Ureterolithiasis Salpingo-oophoritis (adnexitis) Diffuse abdominal pain • • • • Peritonitis Intestinal obstruction Irritable bowel syndrome Tense ascites • • • • • • • 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 History taking Other causes abdominal pain • • • • • • • • Diabetic ketoacidosis Hyperthyroidism Acute intermittent porphyria Hypercalcemia, hyperkalemia Vasculitis Pneumonia Sickle cell crisis Herpes zoster 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 History taking Substernal pain Cardiac pain Esophageal pain Radiation: left Type: pressing, constricting Aggravating factors: physical activity, stress Relieving factors: nitrates Associated symptoms: dyspnoea, sweating Radiation : back Type:burning, spasmodic Aggravating factors: body position, eating Relieving factors: antacid Associated symptoms: dysphagia,regurgitation History taking Dysphagiadifficulty 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 History taking Weight 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 History taking Nausea 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 History taking Nausea 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 History taking Abdominal gas • Belching, bloating (meteorism), flatulence • Causes – Aerophagia (habitual, poor dentition, inadequate chewing, rapid eating) – GI motor dysfunction or obstruction – Malabsorption, maldigestion – Bacterial overgrowth History taking Bowel 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 History taking Bowel movement • Stool alterations – colour – Content - hypocholic, acholic - pleiochromic - bloody - mucus - blood - fat - steatorrhea - undigested proteins creatorrhea History taking Bowel movement • Mechanisms of diarrhea – pathological motility – increased bowel permeability – decreased absorption – intraluminal osmotic factors History taking Bowel 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 History taking GI bleeding • Classification – Hematemesis – Melena – Hematochezia – Occult bleeding - fresh blood - coffee ground - black - blood on the stool - blood mixed with the stool History taking Causes 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 History taking Causes 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 History taking Jaundice • 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 History taking Causes 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 History taking Jaundice • 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 Physical examination of the abdomen 1.Inspection 2.Auscultation 3.Percussion 4. Palpation Position of the patient Physical examination Inspection • 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 Physical examination Abdominal distension • Generalised • Localised • • • • • • • • • • • • Obesity Pregnancy Ascites Bowel obstruction ileus • Big ovarian cyst • Peritonitis Hepatomegaly Splenomegaly Polycystic kidney Gastric distension Inflammatory mass Tumor Obstructed bladder Hernia Physical examination Auscultation • 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 splash normal: above the stomach pathologic: bowel obstruction Physical examination Percussion • Meteorism • Liver span midclavicular line: 6-12 cm midsternal line: 4-8 cm • Splenic dullness norm: in the midaxillary line pathological:dullness in the ant. axillary line during inspiration • Liver or/and splenic dullness absent: perforation • Ascites shifting dullness Ascites shifting dullness Physical examination Palpation • Position of the patient • Warm hands, short fingernails • Approach slowly, avoid quick movements • Exemine tender areas at last • Watch the patient’s face Physical examination Palpation 1. Light palpation a. muscular resistance - guarding b. alterations in the abdominal wall Physical examination Palpation 2. Deep palpation a. assessing abdominal masses b. assessing abdominal tenderness Physical examination Palpation • Characteristics of an abdominal mass 1. 2. 3. 4. 5. 6. 7. 8. location size shape consistency surface tenderness movable or fixed shifting by respiration Physical examination Palpation of the liver and spleen • Characteristics: 1. size 2. surface 3. edge 4. consistency 5. tenderness Palpation of the spleen • 1. supine position • 2. right lateral position Physical examination Palpation 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 Physical examination Palpation of the aorta • • • • to the left of the midline normal: < 3-4 cm >6 cm: aortic aneurysm transmitted pulsations: pancreatic or gastric tumor, pseudocyst of the pancreas Physical examination Signs of peritonitis • Guarding - defense musculaire • Pain produced by coughing • Tenderness (by palpating or percussing) • Rebound tenderness Physical examination Rectal digital examination • • • • • • Perianal diseases fistulas, masses Anal alterations hemorrhoids, fisssuras, masses Rectal alterations polyp, neoplasm, ulcer Prostate gland Douglas’s space Stool on the glove