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Propedeutics- Gastroenterology 1.. History taking in abdominal diseases.

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Presentation on theme: "Propedeutics- Gastroenterology 1.. History taking in abdominal diseases."— Presentation transcript:

1 Propedeutics- Gastroenterology 1.

2 History taking in abdominal diseases

3 History taking Abdominal pain Localisation Type Severity Chronology Aggravating or relieving factors Associated symptoms Radiation of pain

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6 Right upper quadrant (RUQ) Cholelithiasis, cholecystitis, cholangitis Duodenal ulcer Pancreatitis Hepatitis, hepatic congestion Colon cancer Nephrolithiasis, hydronephrosis, pyelonephritis Pulmonary causes Diaphragmatic pain

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

8 Left upper quadrant (LUQ) Colon cancer Colitis, irritable colon syndrome Pancreatitis, pancreatic cancer Splenic causes Nephrolithiasis, hydronephrosis, pyelonephritis Pulmonary causes Diaphragmatic

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

10 Lumbar Kidney stone Pyelonephritis Perinephritic abscess Colon cancer

11 Right lower quadrant (RLQ) Appendicitis Colon cancer Crohn’s disease Ureterolithiasis Salpingo-oophoritis (adnexitis)

12 Hypogastric Cystitis Salpingitis Ectopic pregnancy Prostatitis Colonic pain

13 Left lower quadrant (LLQ) Diverticulitis Colon cancer Ulcerative colitis Ureterolithiasis Salpingo-oophoritis (adnexitis)

14 Diffuse abdominal pain Peritonitis Intestinal obstruction Irritable bowel syndrome Tense ascites

15 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

16 History taking Other causes abdominal pain Diabetic ketoacidosis Hyperthyroidism Acute intermittent porphyria Hypercalcemia, hyperkalemia Vasculitis Pneumonia Sickle cell crisis Herpes zoster

17 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

18 History taking Substernal pain Cardiac pain Radiation: left Type: pressing, constricting Aggravating factors: physical activity, stress Relieving factors: nitrates Associated symptoms: dyspnoea, sweating Esophageal pain Radiation : back Type:burning, spasmodic Aggravating factors: body position, eating Relieving factors: antacid Associated symptoms: dysphagia,regurgitation

19 History taking Dysphagia- 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

20 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

21 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

22 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

23 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

24 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

25 History taking Bowel movement Stool alterations –colour - hypocholic, acholic - pleiochromic - bloody –Content - mucus - blood - fat - steatorrhea - undigested proteins - creatorrhea

26 History taking Bowel movement Mechanisms of diarrhea –pathological motility –increased bowel permeability –decreased absorption –intraluminal osmotic factors

27 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

28 History taking GI bleeding Classification –Hematemesis - fresh blood - coffee ground –Melena - black –Hematochezia - blood on the stool - blood mixed with the stool –Occult bleeding

29 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

30 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

31 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

32 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

33 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

34 Physical examination of the abdomen 1.Inspection 2.Auscultation 3.Percussion 4. Palpation

35 Position of the patient

36 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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38 Physical examination Abdominal distension Generalised Obesity Pregnancy Ascites Bowel obstruction - ileus Big ovarian cyst Peritonitis Localised Hepatomegaly Splenomegaly Polycystic kidney Gastric distension Inflammatory mass Tumor Obstructed bladder Hernia

39 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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41 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

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44 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

45 Physical examination Palpation 1. Light palpation a. muscular resistance - guarding b. alterations in the abdominal wall

46 Physical examination Palpation 2. Deep palpation a. assessing abdominal masses b. assessing abdominal tenderness

47 Physical examination Palpation 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

48 Physical examination Palpation of the liver and spleen Characteristics: 1. size 2. surface 3. edge 4. consistency 5. tenderness

49 Palpation of the spleen 1. supine position 2. right lateral position

50 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

51 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

52 Physical examination Signs of peritonitis Guarding - defense musculaire Pain produced by coughing Tenderness (by palpating or percussing) Rebound tenderness

53 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


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