1. Gastroenterology Pathology
Conrad Ross, PA-C SMDC GI

2. History Nature & course of abdominal symptoms Pneumonic: OLD CARTS
Associated s/s
Past medical, family & surgical Hx
Medications
Could you be pregnant?

3. Pain Onset Location Duration Character
Aggravating / Alleviating Factors
Radiation
Treatments
Signs/Symptoms Associated

4. Physical Assessment
Inspection
Auscultation
Percussion

5. Physical Examination Palpation Abdominal Quadrants
(Further Diagnostic Areas)
Referred Pain
Special Tests
(Murphy’s sign, Carnett’s Sign)

6. Abdominal Pain DDX Appendicitis Cholelithiasis
Irritable Bowel Syndrome
Inguinal Hernia
Esophageal Reflux/Indigestion
Colitis
Ulcer
Diarrhea/constipation
Gastroenteritis
Gastritis
Crohn’s Disease
Trauma – spleen, liver, hollow viscous

7. Appendicitis
Pain usually (70%) starts centrally (umbilical region) and moves to Mcburney’s Point
The RLQ becomes tender in 65%-95% of cases
Most common acute surgical condition of the abdomen
Occurs in about 7% of population, between age yrs old

8. Appendicitis: Pathogenesis
Long finger-like process that extends from the inferior tip of the cecum
Obstruction of the narrow lumen initiates the clinical illness
D/T viral illness or fecal obstruction (fecaliths)

9. Appendicitis
S/S: Periumbilical abdominal pain, nausea, fever, pain with motion, advanced stage sepsis due to bowel perforation.
Tests: inspection normal to immobile patient, can look quite ill. Labs abnormal elevated CRP, WBCs, abnormal palpation
Tx/Complications: Immediate surgical referral, if septic life threatening.

10. Appendicitis-Tests
Psoas Sign

11. Appendicitis - Tests
Obturator Sign

12. Irritable Bowel Syndrome
Common disorder, cause unknown, diagnosis of exclusion
S/S: intermittent loose stools, intermittent constipation, relation to foods, relation to stress (anxiety and depression), distention of bowel causing pain.
GI Bleeding, fever, weight loss, and persistent severe pain are NOT s/s of IBS

13. IBS – cont.
Diagnosis: Again of exclusion, Rome III diagnostic criteria* for irritable bowel syndrome
Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months associated with 2 or more of the following
(1) Improvement with defecation
(2) Onset associated with a change in frequency of stool
(3) Onset associated with a change in form (appearance) of stool
Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. Discomfort means an uncomfortable sensation not described as pain. In pathophysiology research and clinical trials, a pain/discomfort frequency of at least 2 days a week during screening evaluation for subject eligibility.
Reproduced with permission from Longstreth, GF, et al. Gastroenterology 2006; 130:1480.
TX: Treatment is directed at symptoms not cause. Diarrhea- antidiarrheal, Constipation- Fiber, Miralax, MOM, Anxiety- Ativan etc. Depression –SSRIs, Tricylcics, Pain-Antispasmodics, Anitcholanergics, Physical Therapy, muscle release. Avoid Narcotics.
BRAT Diet: Bananas, Rice, Applesauce and Toast

15. Inguinal Hernia
Definition: A hernia is the protrusion of a portion of an organ or tissue through an abnormal opening in the wall that normally contains it. In this case the Inguinal area. Can be direct or indirect.
s/s: painless to painful bulge in RLQ,LLQ, worse with motion, lifting. If no bowel movements worrisome for incarcerated bowel (surgical emergency).
Tx: referral to surgeon
Can be difficult to diagnose. Common when born

16. Ulcers
Excessive secretion of gastric acids, inadequate protection of mucus membrane, stress, heredity, medications
s/s: mid epigastric, gnawing abdominal pain radiating to back, improved with eating, tarry stools, anemia
Dx: Exam, UGI x-ray, CBC, EGD
Tx: Hold offending meds (NSAIDS), twice daily PPI. Treat h. Pylori if present. Reevaluate

17. Esophageal Reflux Heartburn
Cause: Transient relaxation of the lower esophageal sphincter intrinsic pressure, angle of cardioesphygeal junction, action of diaphragm, gravity.
s/s: Retro sternal, non exertional chest pain, with or without episodes of regurgitation.
Dx: Based on symptoms, sometimes seen on UGI.
Tx: If no alarm symptoms then PPI and re-evaluate. If alarm sxs: dysphagia, GI bleeding or weight loss then EGD needed.

18. Diarrhea
Causes: infection, drug-induced, food related, post-surgical, psychological, exercise (runner’s trot)
s/s: Three or more bowel movements per day are considered to be abnormal, and the upper limit of stool weight is generally agreed to be 200 g per day in Western countries.
Dx: Multiple studies, stool o&p, stool culture, stool c.diff toxin, stool fecal fat and if no cause and chronic then colonoscopy and blood work, watch electrolytes.
Tx: Aim at underlying cause, mostly supportive with low glucose electrolyte solution, watered down Gatorade.
BRAT diet: Avoid lactose, bland diet. No ETOH.

19. Runners Diarrhea Incidence
Runners Diarrhea affects 35% of runners in 10k race
Mechanism
Increased intestinal motility with intense Running
Caused by gastrointestinal peptide
Possibly related to bowel ischemia
Symptoms and Signs
Watery Diarrhea
Increased stool frequency
Large volumes
Bloody stool in 12% of patients
Diffuse nonlocalized low Abdominal Pain
Tenesmus
Recommendations
Establish pre-run ritual
Avoid eating 2 to 3 hours before Running
Decrease dietary sugars
Lactose
Fructose
Aspartame (Nutri-sweet)
Sorbitol
Decrease Dietary Fiber or use liquid meals before race
Decrease caffeine intake
Avoid mints or gum containing Sorbitol
Avoid large Vitamin Doses (especially Vitamin C)
Switch training time of day to evening
Stay conditioned
Consider anti-Diarrheal drugs
Consider temporary decrease in miles or intensity
Initially decrease program by 20-25%
Slowly re-increase Exercise program
Consider rice-based electrolyte solution (CeraSport)
Anecdotal evidence only

20. Constipation Definition: Three or less bowel movement weekly
S/S: bloating, early satiety, bulging abdomen, painful defecation, nausea, abdominal pain
Dx: History, KUB with sitz marker study
Tx: Fiber, water, exercise, Miralax, Amitiza, MOM, think about pelvic floor dysfunction, biofeedback

21. Gastroenteritis
Definition: Literally inflammation of gastrointestinal system resulting in a plethora of symptoms from N/V to diarrhea. Usually attributed to viral or bacterial cause.
Cause: E. Coli infection, staphylococcal food poisoning, botulism, viral, chemical or drug related
S/S: N/V, steatorrhea, bloody stools, dehydration, weakness, abdominal pain relieved by bowel movements.
Dx: Stool studies, O&P, Stool cultures, stool for fat, c.diff toxin, stool for fat. BMP
Tx: Usually supportive, fluids, water down Gatorade, let run it’s course avoid anti diarrheals, consider pepto, if longer than two weeks further investigation. Bland diet (BRAT) avoid milk products.

22. Ulcerative Colitis Cause: Unknown, ?autoimmune
S/S: Loose stools w/ w/o blood, nocturnal stools, iron deficiency anemia, LLQ abdominal pain.
Dx: Usually on colonoscopy, some IBD serology
Tx: prednisone, asacol

23. Crohn’s Disease
S/S: Will present with diarrhea, blood in stool, pain nonspecific to generalized.
Dx: Labs, colonoscopy
Tx: Immunosuppressive medications. Last resort surgical removal of ulcerated portion

24. Abdominal Trauma Common sports
Key is immediate recognition, monitoring & management

25. Abdominal Trauma
Screening tools: exam and History observe for abdominal distention or falling BP rising pulse without explanation
Ultrasound: +/-
Diagnostic Peritoneal Lavage: +/-
Computed Tomography: +/-

26. Splenic Injuries Most commonly injured organ in abdomen
Deceleration causes a shearing force on vessels and capsule
Blunt trauma to LUQ

27. Splenic Injuries
S/S: LUQ pain radiating to back, severe, sharp unrelenting to dull ache after trauma, some ecchymosis
Tx: avoid surgery if possible
Return to play: 6-8 weeks depending on recovery and sport activity.
Al Harris- DB Green Bay

28. Liver Injuries 2nd most common injured
Blunt trauma to RUQ, lower chest from front or back
s/s: RUQ ache radiating to back, usually contusion of ribs, achy in character.
Tx: Usually supportive with monitoring.

29. Still more options Are you pregnant?, reproductive diseases
Ovarian Cysts, PID, Endometriosis
UTI or bladder infection, Kidney stones
Can be secondary to appendicitis
Pylonephritis

30. Summary
If fever, bloody stool/urine, pallor, distress, no body movement, unexplained weight loss or severe pain are present, something serious is wrong!!

31. Resources

32. ???Questions???