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Dr. J.A. Coetser Department of Internal Medicine

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Presentation on theme: "Dr. J.A. Coetser Department of Internal Medicine"— Presentation transcript:

1 Dr. J.A. Coetser Department of Internal Medicine CoetserJA@ufs.ac.za

2  Site  Onset  Character  Radiation  Alleviating factors  Timing  Exacerbating factors  Severity

3  Site Where is the maximum intensity of the pain? Parietal peritoneum involvement gives very localized pain E.g. appendicitis

4  Onset Is pain acute or chronic? When did it begin? How often does it occur?

5  Character and pattern Colicky or steady? Colicky pain due to peristaltic movements  Bowel obstruction  Urethers

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7  Radiation  To the back = pancreatic disease / peptic ulcer  To the shoulder = diaphragmatic  To the neck = oesophageal reflux

8  Alleviating factors Antacids may relieve peptic ulcer or reflux pain Defaecation or passing of flatus may relieve pain from colon disease Rolling around may relieve colicky pain Lying very still may relieve pain from peritonitis

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10  Timing Pain from peptic ulceration may be related to meals Ask about the daily pattern of pain

11  Exacerbating factors Eating may precipitate ischaemic pain or pancreatic pain Coffee, alcohol, spicy food may exacerbate reflux

12  Pattern of peptic ulcer disease pain Dull or burning epigastric pain Episodic May occur at night, may wake patient Pain often unrelated to meals

13  Pattern of pancreatic pain Epigastric pain Relieved by sitting up and leaning forward Pain often radiates to back Vomiting often associated

14  Pattern of biliary pain Rarely colicky Epigastric pain with cystic duct obstruction Usually severe, constant for hours History of similar episodes in past If cholecystitis develops, pain can shift to right hypochondrium

15  Pattern of renal colic pain Colicky pain superimposed on background of constant pain in renal angle Often radiates to groin

16  Pattern of bowel obstruction pain Colicky pain If obstruction is in small bowel, pain often periumbilical Colonic pain can occur anywhere Small bowel obstruction colic cycles every 2-3 minutes Large bowel obstruction colic cycles every 10-15 minutes Obstruction often associated with vomiting, constipation, and abdominal distension

17  Anorexia + weight loss Consider malignancy Depression could also be a cause  Increased appetite + weight loss Malabsorption of nutrients Thyrotoxicosis  Liver disease may cause disturbance of taste

18  Early satiation can be due to gastric diseases Gastric cancer Peptic ulcer

19  Causes GIT infections, e.g. S.aureus Small bowel obstruction Pregnancy Drugs (digoxin, opiates, dopamine agonists, chemotherapy) Peptic ulcer disease with gastric outlet obstruction Gastroparesis from e.g. diabetes mellitus Acute hepatobiliary disease Alcoholism Psychogenic vomiting Eating disorders e.g. bulimia Raised intracranial pressure

20  Timing of vomiting Delayed >1h after meal = gastric outlet obstruction Early morning vomiting = pregnancy, raised intracranial pressure, alcoholism  Contents of vomitus Bile = connection between stomach and duodenum Old food = gastric outlet obstruction Blood = ulceration

21  Heartburn Retrosternal burning pain or discomfort, due to inappropriate relaxation of lower oesophageal sphincter Aggravated by bending or lying down Relieved by antacids  Acid regurgitation Sour or bitter tasting fluid coming up into mouth  Waterbrash Excessive secretion of saliva into mouth, associated with peptic ulcer disease or oesophagitis

22  Dysphagia = difficulty in swallowing Can occur with solids or liquids  Odynophagia = painful swallowing Causes  Infectious oesophagitis  Peptic ulceration  Caustic damage to oesophagus  Ask patient to point to site where food gets stuck

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24  Dysphagia + heartburn = possible stricture formation  Dysphagia only with 1 st few swallows = lower oesophageal ring / oesophageal spasm  Progressive dysphagia for solids = stricture / carcinoma / achalasia  Dysphagia for both solids and liquids = motor disorders, e.g. achalasia

25  Increased frequency of stools (>3 per day)  Change in consistency, loose and watery  Distinguish between acute and chronic diarrhoea

26  Secretory  Osmotic  Abnormal intestinal motility  Exudative  Malabsorption

27  Secretory diarrhoea High volume Persists when patient fasts Occurs when secretion in GIT exceeds absorption, e.g. cholera  Osmotic diarrhoea Large volume stools Disappears with fasting Occurs due to excessive solute drag, e.g. lactose intolerance  Abnormal intestinal motility E.g. thyrotoxicosis, irritable bowel syndrome

28  Exudative diarrhoea Small volume stools, but frequent Associated blood or mucus E.g. inflammatory bowel disease  Malabsorption Can result in steatorrhoea = fatty, pale colored, extremely smelly, floating, difficult to flush away >7g fat in 24h stool

29  May refer to: Frequency <3/week Hard consistency Straining to evacuate stools  Causes: Drugs Metabolic Endocrine Neurological Malignancy Pregnancy Perineal problems

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31  Irritable bowel syndrome Can present with alternating constipation and diarrhoea No structural or biochemical abnormality Abdominal pain plus 2 or more:  Pain relieved by defecation  Looser or more frequent stools with onset of abdominal pain  Mucus per rectum  Feeling of incomplete emptying of rectum  Visible abdominal distension

32  Solitary rectal ulcer  Fistula  Villous adenoma  Irritable bowel syndrome

33  Haematemesis Vomiting of blood (coffee-ground vomitus) Ensure this is not from a nose bleed, bleeding tooth socket or coughing up of blood Usually from source proximal to or at duodenum E.g. peptic ulcer disease Mallory-Weiss tear due to repeated vomiting

34  Haematochezia Bright red blood per rectum Blood usually not mixed with stool, found in toilet bowl E.g. haemorrhoids, local anorectal diseases

35  Melaena stools Black, offensive, tarry stools Bleeding from upper GIT  Massive rectal bleeding From distal colon or rectum Angiodysplasia Diverticular disease

36  Angiodysplasia  Diverticular disease

37  Excess bilirubin deposited in skin and sclerae  Ask about colour of urine and stools If pale stools and dark urine = obstructive or cholestatic jaundice Stercobilinogen unable to reach intestine  Ask about abdominal pain Gallstones can cause biliary pain

38  Pruritis Itching of skin Cholestatic liver disease often causes pruritis, worse over limbs  Abdominal bloating and swelling Bloating due to excess gas or irritable bowel syndrome Persistent swelling due to ascites  Lethargy Chronic liver disease Anaemia

39  Drugs indicated in GIT disease: NSAIDs = peptic ulcer disease Anticholinergic drugs = constipation Isoniazid = drug hepatitis Rifampicin = drug cholestasis Anabolic steroids or contraceptives = cholestasis / peliosis hepatis Paracetamol = liver necrosis

40  Surgical procedures can result in jaundice Anaesthesia e.g. halothane Hypoxaemia of liver cells causing ischaemic hepatitis Damage to bile duct during surgery  History of relapsing and remitting epigastric pain, now with acute abdomen = perforated peptic ulcer  Past history of inflammatory bowel disease

41  Occupation, e.g. exposure to hepatitis  Toxin exposure, e.g. vinyl chloride  Travel history  Alcohol history  Contact with someone who had jaundice  Sexual history  Injections, e.g. intravenous drugs, transfusions, dental treatment, tattooing

42  Colon cancer and familial polyps  Inflammatory bowel disease  Coeliac disease

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