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Examination of gastrointestinal system by HX


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Examination of gastrointestinal system by HX

  1. 1. Gastrointestinal System Examination• Surface markings• Liver upper border 5th ICS right on full exp lower border at costal margin on full inspiration• Spleen behind left 9,10,11 ribs, posterior to MCL• Kidneys upper pole lies deep to the 12th rib posteriorly, 7 cm from the midline, the right is 2-3 cm lower than the left. zaw aung 1
  2. 2. • Abdomen can be divided into nine regions by the zaw aung 2
  3. 3. Characteristics of pain (SOCRATES) pain• Site somatic pain well localised sprained ankle viseral pain diffused angina pectoris• Onset• Character describe by adjectives—sharp/dull, Burning/ tingling, boring/stabbing, crushing/tugging. Use the patient own description.• Radiation• Associated symptoms• Timing Since onset Episodic duration and frequency of attacks continuous any changes in severity• Exacerbation and relieving factors relation to food or specific activities or postures effect of medication• Severity subjective variation by day or night ,week or month zaw aung 3
  4. 4. Symptoms and definitions General• Anorexia  loss of appetite• Weight loss  significant >3 kg in 6 months zaw aung 4
  5. 5. Upper GI• DysphagiaDifficulty in swallowingAsk forIs dysphagia painful or painlessIs dysphagia intermittent or progressiveHow longIs there a previous history of dysphagia or heartburn.Is the dysphagia for solids or liquids or bothWhat level does food stickIs there complete obstruction with food regurgitation. zaw aung 5
  6. 6. Causes of dysphagia• Oral Painful mouth ulcers -- tonsillitis, pharyngitis• Neurological -- CVA, bulbar or pseudobulbar• palsy• Neuromuscular---myasthenia gravis, achalasia, pharyngeal pouch• Mechanical ----- oesophageal cancer, peptic oesophagitis, scleroderma, benign stricture, compression zaw aung 6
  7. 7. Heartburn and reflux symptoms• Heartburn ---- burning, hot retrostenal discomfort which radiate upwards . Commonnest cause is reflux oesophagitis.• acid reflux---regurgitation of gastric acid produce a sour taste in the mouth.• Water brash sudden onset of excessive saliva in the mouth is due to reflex salivation, may occur in peptic ulcer disease. zaw aung 7
  8. 8. dyspepsia• Dyspepsia is the pain or discomfort centred in the upper abdomen.• Indigestion is a term used for ill-defined symptoms from the upper GIT. zaw aung 8
  9. 9. • Nausea sensation of feeling sick.• Vomiting is the expulsion of gastric contents via the mouth.• Causes of vomiting• GI causes peptic ulcer, GOO, obstruction of GI tract. gastroenteritis, cholecystitis, pancreatitis, hepatitisNon-alimentary causes of vomiting neurological  ICP, vestibular disorder, migraine, vasovagal syncope, shock, fear and severe pain. Drugs alcohol, opioids, theophyllines, digoxin, cytotoxic agents, antidepressants metabolic/endocrine pregnancy, DKA, renal failure, liver failure, adrenal failure and hypercalcaemia. psychological anorexia nervosa, bulimia zaw aung 9
  10. 10. Questions to be asked for vomiting• Medication history.• vomiting +/- nausea.• Associated with abdominal pain.• Abdominal pain relieved by vomiting.• Vomiting related to meal-times, early morning or late evening.• Vomitus bile-stained, bloodstained or faeculent. zaw aung 10
  11. 11. Haematemesis and malaena• Haematemesis vomiting of blood. Fresh and red, or dark brown coffee grounds colour.• Malaena tarry and shinny black with characteristic odour stool. zaw aung 11
  12. 12. Abdominal distension• Causes• fat obese• Flatus obstruction, pseudo-obstruction• Faeces obstruction, constipation• Fluid ascites, tumours, distended bladder• Fetus• Functional bloating zaw aung 12
  13. 13. ascites• Common cirrhosis with portal hypertension malignancy with peritoneal spread CCF• Uncommon hepatic or portal vein occlusion constrictive pericarditis hypoproteinaemia peritonitis zaw aung 13
  14. 14. jaundice• Yellowish discoloration of the skin, sclerae and mucus membranes due to hyperbilirubinaemia.• Levels of bilirubin >50 umol/L• Causes prehepatic jaundice ( haemolytic) hepatic ( hepatocellular) post-hepatic (obstructive) zaw aung 14
  15. 15. History for jaundice• Appetite and weight change• Abdominal pain, altered bowel habit• GI bleeding• Pruritus, dark color urine, rigors• Drugs and alcohol history• Past medical/surgical history• Previous jaundice or hepatitis• Blood transfusion• Family history• Sexual/contact history• Travel history and immunisations• Skin tatoo. zaw aung 15
  16. 16. History taking Alarm features• Persistent vomiting• Dysphagia• Fever• Weight loss• GI bleeding• Anaemia• Painless, watery, high-volume diarrhoea• Nocturnal symptoms disturbing sleep. zaw aung 16
  17. 17. • Always investigate alarms symptoms particularly those over >50 years. zaw aung 17
  18. 18. Past history• History of similar problems/symptoms may suggest the diagnosis.• Ask about previous abdominal surgery, X-rays, scans and other investigations zaw aung 18
  19. 19. Drug History• Prescribed medications, over-the-counter medications, herbal preparations and indigenous medicines. zaw aung 19
  20. 20. Family history• Inflammation bowel disease is more common in patients with a family history of either Crohn’s disease or ulcerative colitis.• Colorectal cancer in a first degree relative increase the risk of colorectal cancer and polyps.• PU is familial.• Gilbert’s disease, haemochromatosis, Wilson’s zaw aung 20
  21. 21. Social history• Dietary history and assess the approximate intake of calories and sources of essential nutrients.• Specific food intolerance• Alcohol consumption in units• Smoking• Any mental stress• Risk factors for hepatitis.• Foreign travelling. zaw aung 21
  22. 22. Physical Examination• General examination• nutritional state record the height, weight, waist circumference and the patient’s body mass index.• Obesity truncal or generalised.• Abdominal striae• Loose skin fold• Stigmata of iron deficiency, koilonychia, angular stomatitis and atrophic glossitis.• Muscle wasting.• Fever. zaw aung 22
  23. 23. hands• Clubbing• Koilonychia• Signs of liver disease –leukonychia - palmer erythema - flapping tremors - zaw aung 23
  24. 24. face• Pallor• Jaundice• Spider naevi• Parotid swelling• Mouth- angular stomatitis, glossitis, teeth and gums• Neck goitre, neck glands zaw aung 24
  25. 25. Legs• Oedema• Pyoderma gangrenosum zaw aung 25
  26. 26. zaw aung 26
  27. 27. zaw aung 27
  28. 28. Abdomen• Normal appearance flat, scaphoid and symmetrical.• Normal findings liver edge may be felt below the right costal margin.• Aorta may be palpable as pulsatile swelling.• Lower pole of the right kidney may be palpable.• Faecal mass may be palpable.• Distended bladder zaw aung 28
  29. 29. Inspection• Skin striae, bruising or scratch marks.• distended veins superior vena cava, inferior vena cava and, portal hypertension (caput medusae).• Distension of abdomen. Generalised or localised.• Scars and stomas• Movements normal movements- still, silent abdomen in generalised peritonitis.• Epigastric palpation.• Visible peristalsis GOO, distal small bowel obstruction, normal very thin, elderly patients.• Pigmentation of skin -linea nigra• -erythema ab igne -- brown mottled pigmentation on the skin of abdominal wall. zaw aung 29
  30. 30. Palpation, Percussion, Auscultation • Light palpation tenderness rebound tenderness palpable mass • Deep palpation enlarged organs, liver, spleen, kidneys, gall bladder. • Percussion liver, spleen, shifting dullness fluid thrill. • Auscultation bowel sounds, aorta (above umbilicus), renal bruits, liver bruits, rub succussion splash. zaw aung 30
  31. 31. zaw aung 31