SYMPTOMS & SIGNS IN GIT PROBLEMS امراض ہضم کی علامات و نشانیاں

1. SYMPTOMS & SIGNS
IN GI PROBLEMS
‫کی‬ ‫ہضم‬ ‫امراض‬
‫نشانیاں‬ ‫و‬ ‫عالمات‬
Dr Syed Ayesha Fatema
MD Medicine
Professor
PG dept of Moalijat
ZVMUMCH Pune

2. SYMPTOMS IN GI
PROBLEMS
‫کی‬ ‫ہضم‬ ‫امراض‬
‫عالمات‬

3. SYMPTOMS IN GI PROBLEMS
• Pain abdomen
• Difficulty in swallowing- Dysphagia
• Vomiting
• Heartburn- Retrosternal pain- Pyrosis
• Indigestion
• Change in bowel habits- Constipation /
Diarrhea
• Loss of appetite/ Loss of weight

4. BASIC QUESTIONS YOU WOULD ASK IN ABDOMINAL
PAIN
 When did the pain start?
 Where is it, show me?
 Have you ever had it before?
 Did it come on suddenly or
gradually?
 Does it go anywhere else?
Show
 How bad is it, worst you have
ever had, severe, very severe,
mild, moderate, just an ache
(do not use x/10 unless you
define 10)?
 Is it the same all the time?
 Have you had time completely
free of pain since it started?
 Is it constant or comes in
waves?
 Is it getting worse?
 What makes it better, e.g. lying
still / painkillers?
 What makes it worse, e.g.
moving about?
 Have you got any other
symptoms with it, give
examples, e.g. vomiting/fever

5. BASIC QUESTIONS YOU WOULD ASK IN
DYSPHAGIA
 How long have you had
the problem?
 Describe what it is like?
 Have you had it before?
 Did it come on gradually or
suddenly?
 Is it becoming worse?
 Do you have difficulty with
solids and/or liquids?
 Which came first?
 Does the food seem to
stick. Show me where?
 Have you been vomiting,
what, etc
 How is your appetite?
 Have you lost weight?
 Plus, all the other GI
protocol questions
 Plus, do you feel anything
else wrong with you at
present.

6. BASIC QUESTIONS YOU WOULD ASK IN
VOMITING
 When did the vomiting
start?
 What do you vomit?
 Is it food/ water/ bile/ greeny
stuff /acid/blood?
 If food, is it food you have
just eaten or old food?
 If it is blood, how do you
know?
 Amount, color, clots, coffee
grounds.
 How often do you vomit?
 Do you feel sick nauseated)
all the time?
 Does anything bring the
vomiting on(worse)?
 Does anything make it
better?
 Does it shoot out with great
force (projectile)?
 Any coughing or choking?

7. BASIC QUESTIONS YOU WOULD ASK IN
RETROSTERNAL PAIN
 Describe it to me .
 How long have you had it?
 Have you had it before this
episode?
 Did it come on gradually or
suddenly?
 Is it becoming worse?
 What makes it worse (e.g. lying
down in bed, bending over,
certain types of food and drink-
spicy food/ alcohol/ coffee)?
 What makes it better ( sleeping,
sitting up, avoiding certain
drinks or food, medications)?
 Do you get any acid reflux-acid
or water coming into your
mouth, describe this please
(distinguish acid reflux and
water-brash).
 Do you have any difficulty
swallowing? Describe.
 Do you have any pain behind
the chest bone? Describe.
 Do you vomit?
 Do you have indigestion?
 Have you put on weight
recently?

8. BASIC QUESTIONS YOU WOULD ASK IN
INDIGESTION
 Do you have any indigestion, if
says 'yes'?
 Ask what do you mean by this, if
says 'no; ask: do you have any
discomfort or pain in your tummy
after eating?
 Where is the discomfort, show
me (pointing sign of DU)?
 When do you get it-before
meals/ after meals?
 Does it wake you at night (DU),
what do you do about it, e.g. get
up have some milk and a
biscuit?
 How often do you get it, e.g.
every day?
 Have you had it before?
 Have you seen your GP about it
or been investigated in hospital
(e.g. endoscopy)?
 What did they say was wrong
with you?
 What makes the indigestion
worse/better?
 Have you been vomiting any
blood?
 How is your appetite; have you
lost weight?
 Do you take any medications for
it (define)?
 Are you taking aspirin / NSAIDs
/ steroids/ herbal medications?

9. BASIC QUESTIONS YOU WOULD ASK IN
ALTERED BOWEL HABITS
 Has your bowel habit
changed recently?
 If patient does not appear to
understand-Explain.
 Have you developed
diarrhea or constipation
recently (means different
things to different people)?
 Define their normal bowel
habit.
 Define what it has changed
to, e.g. normal is x 1 per day
now is x 3 per day.
 If has diarrhea-define
content, color, offensive,
blood/floats
 If has constipation-is it
constipation or incomplete
evacuation? or even
tenesmus
 Have you passed any blood
or slime? Define both.
 Have you had any abdominal
pain or weight loss?
 On any drugs ( e.g.
antibiotic)?

10. BASIC QUESTIONS YOU WOULD ASK IN DIARRHEA
 Frequency of defecation
(>x3 = abnormal).
 Recent or present for long
time.
 Solid/liquid/mixed./?
 Bulky may be steatorrhea.
 Color:
 Black (melena),
 red (blood),
 pale (steatorrhea,
obstructive jaundice),
 silver (because of mixture
of melena and fatty stool in
tropical sprue, carcinoma
(Ca) of ampulla of Vater).
 Pus or mucus.
 Smell-very offensive, may be
infective/melena.
 Floats/ difficult to flush away,
may be steatorrhea.
 Any other symptoms, e.g.
vomiting.
 Been abroad recently.
 Anyone else in family with it
(gastroenteritis).
 NB: Some gastroenterologists
divide by physiological cause
into secretory, osmotic,
exudative, malabsorption (not
very useful in practice).

11. BASIC QUESTIONS YOU WOULD ASK IN
CONSTIPATION
 What do you mean by
constipation infrequent bowel
action or very hard motion or
difficulty in evacuation?
 Is this a new symptom or long
standing?
 If recent, define 'change': Normal
bowel habit versus old bowel
habit.
 Any blood or mucus?
 Incomplete emptying-have to go
again-is a symptom of pelvic
floor descent or rectal cancer-
Tenesmus
 Any incontinence- overflow or
otherwise?
 Painful almost continuous urge
to defecate is tenesmus (rectal
equivalent of urinary strangury)
indicates inflammation or tumor
involving anal sphincters.
 Other GI symptoms, e.g.
abdominal pain/distension.
 On any drugs, e.g. codeine.
 Alternating diarrhea +
constipation,
 some say symptom of tumor but
more likely irritable bowel
syndrome (large bowel tumor is
more often change from normal
to more frequent).

12. BASIC QUESTIONS YOU WOULD ASK IN LOSS
OF APPETITE/ LOSS OF WEIGHT
Loss of appetite
 When did this happen,
did it start same time as
other GI symptoms?
 Loss of appetite
(anorexia) + weight loss =
Suspicious of
malignancy.
 Increase in appetite, may
suggest hypermetabolic
state, e.g. thyrotoxicosis
Loss of Weight
 When did it start?
 How much (in kg over
weeks) if patient not sure,
ask about loose clothes?
 Why do you think lost
weight-may say on diet? -
intentional or unintentional
 Are there other symptoms
may need full review of
systems, e.g. fever/thirst?

13. ‫نشانیاں‬ ‫کی‬ ‫ہضم‬ ‫امراض‬
SIGNS IN GI PROBLEMS
(PHYSICAL EXAMINATION)

14. ABDOMINAL EXAMINATION
INTRODUCTION (WIPER)
W - Wash your hands.
 I - Introduce yourself to the patient
P -Permission. Explain that you wish to perform an
abdominal examination and obtain consent for the
examination. Pain. Ask the patient if they are in any pain and
to tell you if they experience any during the examination.
E -Expose the necessary parts of the patient. Ideally
patients should be exposed from xiphisternum to pubis
(classically they should be exposed from “nipples to knees”,
but this is rarely done in practice to preserve patient dignity).
Ensure adequate privacy.
R -Reposition the patient. In this examination the patient
should be lying flat with one pillow under the head. This is
not possible with all patients so first check if they are
comfortable in this position.

15.  During the examination of the abdominal system a
lot of information can be obtained by looking for
peripheral signs of gastro-intestinal disease.
 The examination is therefore split into a peripheral
examination and then an examination of the
abdomen.

16. PERIPHERAL EXAMINATION
 End of the Bed
 • First look at the patient from the end of the bed for
signs of anxiety or distress.
 • Note any weight loss and assess level of hydration and
general well being. Are there signs of easy bruising?
 • Are there any drains, stoma bags or signs of an AV
(arteriovenous) fistula?
 • It is also important to look at the surrounding
environment for sick bowels, food supplements, special
dietary notices and ‘nil by mouth’ instructions etc.

17. FACE:
 Jaundice
 Lemon yellow (uremia, CA
cecum, pernicious anemia)
 Weight loss (temporalis muscles,
cheeks )-
 Cachexia
 Dehydration
 Distress (pain)
 Pale (anemia/pain)
 Flushed (temperature)
 Parotid swelling (alcohol abuse,
iron deficiency anaemia) and
 Bruising.
EYES:
 Yellow sclera (Jaundice)
 Pale mucous membranes of
conjuctiva (anaemia)
 Xanthelasma (chronic
cholestasis)
 Kayser-Fleischer rings (Wilson's
disease, primary biliary
cholangitis and children with
neonatal cholestasis)
MOUTH:
 Angular stomatitis (B12
deficiency, Fe deficiency)
 Pigmentation (Peutz-Jeghers
syndrome)
 Aphthous Ulcers (Crohn's
disease)

18. TONGUE
 Glossitis.
 Red and beefy = folate /B12 deficiency
 atrophic and smooth = iron deficiency
HANDS:
 Finger nails leukonychia (low protein)
 Koilonychia (Fe deficiency)
 Clubbing (UC/Cirrhosis)
 Palmar erythema, and
 Dupuytren’s contracture
PALMS:
 Pale creases (anemia)
 Palmar erythema (liver failure)
 Liver flap (liver failure)
ARMS:
 Scratch marks ( obstructive jaundice)

19. NECK:
 Enlarged lymph nodes (supraclavicular -
 CA stomach)
LEGS:
 Superficial thrombophlebitis
 (Pancreatic CA)
AXILLA:
 Acanthosis Nigricans (Ca stomach)
 Irish nodes ( Ca stomach)
CHEST:
 Spider nevi (>5 is abnormal) (liver failure)
 Gynecomastia (liver failure)
 Distribution of body hair, particularly paucity of hair (liver
disease).

20. EXAMINATION OF THE ABDOMEN
 Inspection
 First inspect abdomen from the end of the bed
before closer inspection at bedside.
 Initially look for general signs such as weight loss.
 Then check specifically for other signs.

21. ABDOMEN:
Inspection:
 Shape or symmetry
 No movement with respiration
(peritonitis)
 Jaundiced skin
 Distended (obstruction,
ascites, 5Fs – flatus, faeces,
foetus, fat, fluid)
 Weight loss (malignancy)
 Scars (previous surgery) and
striae
 Fistula (Crohn's)
 Everted umbilicus (ascites)
 Mass ( tumor, abscess)
 Visible peristalsis (intestinal
obstruction or chronic pyloric
stenosis )
 Pulsatile Swelling-
Expansile/transmitted (hernia)
 Enlarged veins + caput
medusa (liver disease)
 Cullen's/Grey Turner's
sign(pancreatitis)
 Erythema (pain /hotwater
bottle use)
 Cellulitis ( abscess-diverticular
disease/ tumor)

22.  Palpation
 Position yourself by kneeling or sitting on the patient’s
right hand side. Ensure your hands are warm. Ask patient
if they have any pain or tenderness.
 Begin with light palpation of the ninth segment. If patient
has complained of pain begin at opposite side.
 Observe patient’s face throughout palpation to ensure
that you are not causing pain.
 Light palpation is used to assess tenderness and
guarding (a sign of irritation of the peritoneum).
 Proceed next to deep palpation of the same nine
segments. Deep palpation is used to assess for masses.
 If appropriate, test for rebound tenderness (a sign of
intra-abdominal pathology)

23. PALPATION:
 Tenderness/ guarding/
rebound (inflammation)
 Rigidity- Perforative
perotonitis
 Mass (tumor)
ORGANOMEGALY:
 Liver (primary
CA/metastases)
 Tender+ enlarged
(hepatitis)
 Small + hard (cirrhosis)
 Spleen-enlarged
 (portal hypertension)
ANORECTAL EXAM:
 Fistula (Crohn's)
 Fissure (Crohn's)
 Abscess (IBD)
 Anal cancer
 Rectal prolapse
 Prolapsed haemorrhoids
 Tumor/polyp felt
 Blood on finger (tumor/lBD)
 Pus/mucus (IBD)
 Black motion (melena)
 pale motion ( obstructive
jaundice/ steatorrhea)

24. METHOD OF PALPATION OF ORGANS
Liver
 A normal liver extends from 5th intercostals space to costal
margin.
 It may be palpable in normal individuals.
 Position your hand in the right iliac fossa with fingers in an
upward position facing the liver edge (alternatively you can
use the radial aspect of your index finger).
 Press your fingertips inward and upward and hold this
position while your patient takes a deep breath.
 As the liver moves downward with inspiration the liver edge
will be felt under fingertips.
 If no edge is felt repeat the procedure closer and closer to
the costal margin until either the liver is felt or the rib is
reached.

25. Spleen
 The normal spleen cannot be felt and only becomes
palpable when it has doubled in size.
 It enlarges from under the left costal margin towards the
right iliac fossa.
 The fingertips of right hand are then positioned obliquely
across the abdomen pointing to the left costal margin
towards the axilla (again, you may use the radial aspect of
your index finger).
 Press your fingertips inward and upward and hold this
position while your patient takes a deep breath.

26.  As the spleen moves with inspiration the edge may be
felt under your fingertips.
 If no edge is felt repeat the procedure closer and closer
to the left lower rib cage until the costal margin is
reached.
 If the spleen is not palpable, this procedure can then be
repeated with the patient rolled onto right lateral position
with knees drawn up to relax abdominal position.
 Palpate with your right hand while using your left hand to
press forward on the patient’s left lower ribs from behind.
 It could be argued that this method should be used first,
since very few patients have spleens which have
enlarged to occupy the right iliac fossa.

27. Kidneys
 The kidneys are retroperitoneal, so not usually palpable
except in some thin individuals.
 To examine left kidney, place the palmar aspect of left hand
posteriorly under left flank.
 Position the middle three fingers of right hand below the left
costal margin, lateral to the rectus muscle (opposite
position of left hand).
 Ask patient to take deep breath and press both fingers
firmly together.
 If the kidney is palpable it will be felt slipping between both
fingers.
 To examine the right kidney repeat the procedure with your
left hand tucked behind the right loin and your right hand
below the costal margin, lateral to the rectus muscle.

28. Aorta
 In thin patients or those with a dilated aorta, the aorta
can be palpated by placing both hands
 on either side of the midline at a point half way
between the xiphisternum and the umbilicus.
 Press your fingers posteriorly and slightly medially and
the pulsation should be present against your
fingertips.

29. Liver
 Begin by establishing lower liver edge.
 Place hands parallel to the right costal margin starting at
the same point as you began palpation.
 Repeat in a stepwise manner moving the fingers closer to
the costal margin until the note becomes duller.
 This is the position of the lower liver edge.
 Next find the upper margin of the liver.
 It can be located by detecting a change in note from the
dullness of liver to resonance of lungs.
METHOD OF PERCUSSION
OF ORGANS

30.  Spleen
 Begin by percussing the ninth intercostal space
anterior to the anterior axillary line (Traub’s space).
 If the spleen is not enlarged the sound will be
tympanic.
 If it is dull continue to percuss in a stepwise manner
moving hands towards right iliac fossa.

31.  Ascites patient
 If fluid is suspected percuss across patients abdomen
(from midline to right flank) until the percussion note
changes from tympanic to dull.
 Mark that spot and then ask your patient to turn onto their
right side (if you are standing on left of patient).
 After 30seconds repeat percussing from the midline
towards the right flank.
 If fluid is present it will have redistributed secondary to
gravity and therefore the area previously marked as
sounding dull to percussion will now be tympanic.
 Bladder
 If the bladder is distended the suprapubic area will be dull
rather than tympanic.
 Percuss from the level of the umbilicus, parallel to the
pubic bone.

32. AUSCULTATION TECHNIQUE
 Bowel sounds
 Place the diaphragm of your stethoscope on the mid
abdomen and listen for gurgling sounds.
 These normally occur every 5-10seconds however you
listen for 30 seconds before concluding that they are
absent.
 Absent bowel sounds indicates intestinal ileus.
 Increased bowel sounds indicate bowel obstruction.

33.  Arterial bruits
 Place diaphragm of stethoscope over aorta and apply
moderate pressure.
 If a systolic murmur is heard this indicates turbulent flow
caused by atherosclerosis or an aneurysm.
 Listen for renal bruits 2.5cm above and lateral to the
umbilicus.
 Then listen over liver and spleen.

34. FINISHING OFF
State that you would complete the examination by:
• Checking for any lympahdenopathy
• Examining the hernial orifices
• Examining the external genitalia
• Performing a digital examination of the anus and
rectum
• Performing a urinary ‘dipstick’ analysis if needed