And Hepatology DISCLAIMER This lecture series has been designed and produced by doctors and students We have made every effort to ensure that the information contained is accurate and in line with learning objectives featured on SOFIA however this guide should not be used to replace formal ICSM ID: 911986
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Slide1
Gastroenterology
Isra Hausien
And Hepatology
Slide2DISCLAIMER
This lecture series has been designed and produced by doctors and students, We have made every effort to ensure that the information contained is accurate and in line with learning objectives featured on SOFIA, however this guide should not be used to replace formal ICSM teaching and educational material.
Slide3HOW TO APPROACH THE ABDOMINAL EXAM
WIPER INSPECTION! INSPECTION! INSPECTION!
HANDS & ARMS
HEAD & NECK
CHEST
ABDOMEN (INSPECTION, PALPATION, PERCUSSION, AUSCULTATION)
Slide4General Inspection
Slide5Hands
Tendon Xanthomata
Dupuytren’s
Contracture
Palmar Erythema
Slide6Clubbing
K
oilonychia
Leuconychia
Slide7Asterixis
(Liver Flap)
Pulse and CRT
Renal Replacement Therapy
Evidence of IVDU
Bruising
Tattoos
Slide8HEAD & NECK
Conjunctival Pallor
Jaundice
Gum Hypertrophy
Slide9Other things to look out for:
Cushingoid (moon face, acne, hirsute)
Parotid enlargement
Corneal arcus
Xanthelasma
(
K
ayser
- Fleischer rings) JVP Lymph nodes
Slide10Chest
Gynaecomastia
Spider
Naevi
- Loss of secondary sexual hair
Slide11Abdomen
Inspection
Distension
6 F’s (Fat, Fluid, Flatus,
Faecus
, Fetus,
Fecking
big masses)
Caput
medusae Portal Hypertension Scars
General palpation
Always start furthest away from tender area
Light and deep palpation
Liver and Spleen
Kidneys
AAA
Slide12Slide13Abdomen
Percussion
Shifting dullness
Percuss away from midline towards left flank
Fluid shifts with gravity
If present i.e. tympanic test +
ve
- suggests ascites (>1.5L of fluid present)
Bladder
Auscultation
Bowel sounds
Active,
tinkling
Renal bruits
Slide14Legs
Peripheral oedema
Erythema
nodosum
IBD
Slide15Summary
Thank patient and allow to re-dress To complete examination
Take a full history
Check
hernial
orifices
DRE
urine dipstick
E
xamine the external genitalia
Slide16Documenting
Date and time Patient details (name, DOB, Hospital No.)
Your name and role
Describe the patient’s general appearance
Abdomen soft non tender (SNT)?
Any abdominal distension, scars, guarding or
organomegaly
?
Signature and name print
#
Mark the area where pain is elicited
Mark areas where
organomegaly
is felt
notingthe
approx
size
Mark scars
Slide17Slide18GI Cases
Dysphagia
Vomiting
Change in bowel habit (constipation/
diarrhoea
)
Jaundice
Upper/Lower GI bleed
Weight Loss
Abdominal painAbdominal distension
Slide19Case 1
A 75 year old gentleman presents to his GP complaining of 2 weeks of bloody stools
PR 84
BP 130/80
Slide20DDx
CANCER
Slide21DDx
Infection: Diverticulitis, Gastroenteritis Inflammation: IBD
Malignancy: Colorectal Ca
Vascular:
Oseophageal
Varices
Miscellaneous:
Haemorrhoids
, peptic ulcer disease, anal fissure
Slide22Hx overview
Introduction
Presenting complaint
History of presenting complaint
(SOCRATES)
Past medical History
Drug history
Family history
Social history
Travel historyICE ICE babySystems review
Slide23PC
Use open questions – the more open the more information you will be told!“
What has brought you in to the hospital/GP today?”
Facilitate the patient to expand on their problems
“So you mentioned X, could you tell me more about this?”
Slide24Our patient
Blood in stoolBeen on holiday for past 2 weeks when it started.
Feels worried
Slide25HPC
SiteO
nset
C
haracter
R
adiation
A
ssociated factors
TimingExacerbating/alleviating factorsSeverity“Has this happened before?”FLAWS Red Flag symptoms
Slide26S
ite – From the back passage? Is the blood mixed in with the stools? Does it coat the stools?Onset- How long has this been going on for?
C
haracter – What does the blood look like? Fresh or black (
malena
)?
R
adiation
Associated factors
Timing – Is the blood there every time? Has it happened before? Exacerbating/alleviating factors – What triggers it? Is it worse e.g. after constipation?
S
everity – How much blood is there? Streaks? Teaspoons?
“Has this happened before?”
FLAWS
Red Flag symptoms
Slide27Associated Factors
CATS PAWS
Change in bowel habit
What is normal like?
Abroad
if so, where?
Tiredness
Swallowing/ upper GIT
Sx
Haematemesis? Heart burn? Pain? Pruritis Ani? If pain, then SOCRATES. Any itching/lumps around the back passage?
Anorexia –
loss of appetite
Weight loss
– important to make sure this is unintentional
Systemic features:
painful red eye? Joint or back pain? Fever? Mouth ulcers?
Slide28PMHx
Ask about previous medicalisation
“Do you have any medical conditions?”
“Have you ever been admitted to hospital for anything?”
“Have you had any previous surgeries?”
Ask about specific relevant conditions that may predispose a patient to their presenting complaint.
Slide29Drug History
“Are you taking any regular medication?”“Any over-the-counter drugs?”
NSAIDs, laxatives, steroids
ALLERGIES!!!!....
if so, what happens?
Slide30Family History
“Has anyone in your family ever suffered from this (presenting complaint)?”“Do any medical conditions run in the family?”
“Any history of
GI cancer
?”
FAP
predisposing factor for malignancy
Slide31Social History
Smoking (how many a day and for how long)
Alcohol (quantify)
Diet
- Fibre? Gluten? Fatty foods?
Recreation drugs
Occupation (how their symptoms have affected their work)
Who are they living with? Support?
(sexual history –hepatitis?)
Slide32Travel History
“Have you travelled abroad recently?” Local Food- Salmonella?
Dirty water-
Campylobactor
, E-coli?
Slide33I.C.E
IDEAS
,
CONCERNS
,
EXPECTATIONS
Your choice when to ask these questions
“What do you think might be going on?”
“Is there anything that is worrying you?”“What are you hoping for us to do for you today?”
Slide34Systems Review
(Only if you have time)
Ask a few questions per different system from top to toe
Rule out big problems in each of these systems that could be present
“I’m just going to finish off by asking you some specific questions now to make sure I haven't missed anything out?”
Headaches, seizures, nausea, cough, breathlessness, chest pain, water works, aches and pain in muscles, rashes
Slide35DDX
CONDITION
SYMPTOMS
SIGNS
INVESTIGATIONS
MANAGEMENT
Colorectal Cancer
L sided:
PR bleeding, change in bowel habit, obstruction, colicky pain
R sided: Low
Hb
, pain, weight loss
O/E
pain,
anaemia
, cachexia, abdominal tenderness
Bloods: low
HbLiver biochemCEA marker Colonoscopy – for diagnosis
Imaging: CT TAP for staging
PET scan
Staging:
Dukes Criteria
Surgery (depends on location)
Chemo/radiotherapy
IBD
(Crohn’s, UC)
Weight
loss, fever, abdominal pain, PR bleeding,
peri
-anal disease
Clubbing,
abdominal
tenderness,aphthous
ulcers,
cushingoid
Bloods: low
Hb
, albumin. High WCC,
CRP/ESR
Stool Culture: exclude infective causes
Imaging: AXR, MRI, capsule endoscopy
Special tests:
leocolonoscopy
+ biopsies
from the terminal ileum and each affected segment
CriteriaInduction
Vs Maintenance
Nutrition
Surgery
Slide36UC
Crohn’s
Slide37CONDITION
SYMPTOMS
SIGNS
INVESTIGATIONS
MANAGEMENT
Haemorrhoids
Tiredness,
Palpable lesions,
fresh blood covering the pan, anal
pruritis
Visible
external
haemorrhoids
Anoscopic
examination Colonoscopy to exclude other serious causes
Bloods: FBCDietary/lifestyle modification Topical corticosteroids Rubber band ligation/ Sclerotherapy
Anal Fissure
Pain on defecation, fresh
blood when wiping.
Visible fissure
Mainly clinical diagnosis
Anal manometry if
resistent
High
fibre
diet
Topical GTN
Botulinum toxin injection
Sphincterectomy
Slide38Questions ?