Propedeutics-Gastroenterology 1.

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Propedeutics-Gastroenterology 1.
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History taking in abdominal diseases

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History takingAbdominal pain

• Localisation
• Type
• Severity
• Chronology
• Aggravating or relieving factors
• Associated symptoms
• Radiation of pain

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Right upper quadrant (RUQ)

• Cholelithiasis, cholecystitis, cholangitis
• Duodenal ulcer
• Pancreatitis
• Hepatitis, hepatic congestion
• Colon cancer
• Nephrolithiasis, hydronephrosis, pyelonephritis
• Pulmonary causes
• Diaphragmatic pain

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Epigastric

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

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Left upper quadrant (LUQ)

• Colon cancer
• Colitis, irritable colon syndrome
• Pancreatitis, pancreatic cancer
• Splenic causes
• Nephrolithiasis, hydronephrosis, pyelonephritis
• Pulmonary causes
• Diaphragmatic

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Periumbilical

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

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Lumbar

• Kidney stone
• Pyelonephritis
• Perinephritic abscess
• Colon cancer

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Right lower quadrant (RLQ)

• Appendicitis
• Colon cancer
• Crohns disease
• Ureterolithiasis
• Salpingo-oophoritis (adnexitis)

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Hypogastric

• Cystitis
• Salpingitis
• Ectopic pregnancy
• Prostatitis
• Colonic pain

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Left lower quadrant (LLQ)

• Diverticulitis
• Colon cancer
• Ulcerative colitis
• Ureterolithiasis
• Salpingo-oophoritis (adnexitis)

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Diffuse abdominal pain

• Peritonitis
• Intestinal obstruction
• Irritable bowel syndrome
• Tense ascites

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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

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History takingOther causes abdominal pain

• Diabetic ketoacidosis
• Hyperthyroidism
• Acute intermittent porphyria
• Hypercalcemia, hyperkalemia
• Vasculitis
• Pneumonia
• Sickle cell crisis
• Herpes zoster

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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

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History takingSubsternal pain

• Esophageal pain
• Radiation back
• Typeburning, spasmodic
• Aggravating factors
• body position, eating
• Relieving factors
• antacid
• Associated symptoms
• dysphagia,regurgitation

• Cardiac pain
• Radiation left
• Type pressing, constricting
• Aggravating factors
• physical activity, stress
• Relieving factors
• nitrates
• Associated symptoms
• dyspnoea, sweating

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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

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History takingWeight loss

• Is it associated with anorexia?
• Chronology
• Severity (significantgt 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

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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

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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

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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

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History takingBowel movement

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

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History takingBowel movement

• Stool alterations
• colour - hypocholic, acholic
• - pleiochromic
• - bloody
• Content - mucus
• - blood
• - fat - steatorrhea
• - undigested proteins -
• creatorrhea

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History takingBowel movement

• Mechanisms of diarrhea
• pathological motility
• increased bowel permeability
• decreased absorption
• intraluminal osmotic factors

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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

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History takingGI bleeding

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

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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

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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

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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

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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

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History takingJaundice

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

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Physical examination of the
abdomen1.Inspection

2.Auscultation3.Percussion4. Palpation

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Position of the patient
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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

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Physical examinationAbdominal distension

• Localised
• Hepatomegaly
• Splenomegaly
• Polycystic kidney
• Gastric distension
• Inflammatory mass
• Tumor
• Obstructed bladder
• Hernia

• Generalised
• Obesity
• Pregnancy
• Ascites
• Bowel obstruction - ileus
• Big ovarian cyst
• Peritonitis

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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

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Physical examinationPercussion

• Meteorism
• Liver span midclavicular line 6-12 cm
• midsternal line 4-8
  cm
• Splenic dullness norm in the midaxillary
  line
• pathologicaldullness in the ant. axillary
  line
• during inspiration
• Liver or/and splenic dullness absent perforation
• Ascites shifting dullness

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Ascites shifting dullness
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Physical examinationPalpation

• Position of the patient
• Warm hands, short fingernails
• Approach slowly, avoid quick movements
• Exemine tender areas at last
• Watch the patients face

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Physical examinationPalpation

• 1. Light palpation
• a. muscular resistance - guarding
• b. alterations in the abdominal wall

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Physical examinationPalpation

• 2. Deep palpation
• a. assessing abdominal masses
• b. assessing abdominal tenderness

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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

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Physical examinationPalpation of the liver and
spleen

• Characteristics
• 1. size
• 2. surface
• 3. edge
• 4. consistency
• 5. tenderness

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Palpation of the spleen

• 1. supine position
• 2. right lateral position

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Physical examinationPalpation of the gallbladder

• Hydrops vesicae felleae
• Curvoisiers sign - painless enlargement of the
  gallbladder due to cancer of the head of the
  pancreas
• Murphys sign - RUQ pain aggravated by
  inspiration - acute cholecystitis

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Physical examinationPalpation of the aorta

• to the left of the midline
• normal lt 3-4 cm
• gt6 cm aortic aneurysm
• transmitted pulsations pancreatic or gastric
  tumor, pseudocyst of the pancreas

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Physical examinationSigns of peritonitis

• Guarding - defense musculaire
• Pain produced by coughing
• Tenderness (by palpating or percussing)
• Rebound tenderness

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Physical examinationRectal digital examination

• Perianal diseases fistulas, masses
• Anal alterations hemorrhoids, fisssuras, masses
• Rectal alterations polyp, neoplasm, ulcer
• Prostate gland
• Douglass space
• Stool on the glove