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

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
Esophageal pain
Radiation : back
Type:burning, 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

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
Physical examination of the abdomen 1.Inspection 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

38. Physical examination Abdominal 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

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

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

43. Ascites shifting dullness

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