History taking in abdominal diseases - PowerPoint Presentation

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History taking in abdominal diseases

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History takingAbdominal pain

Localisation

TypeSeverityChronologyAggravating or relieving factorsAssociated symptomsRadiation of pain

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Right upper quadrant (RUQ)

Gall

stone

, cholecystitis, cholangitisDuodenal ulcerPancreatitisHepatitis, hepatic congestion

Colon

cancer

Nephrolithiasis

,

hydronephrosis, pyelonephritisPulmonary causesDiaphragmatic pain

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Epigastric

Peptic ulcer

Gastro-oesophageal reflux disease

PancreatitisCholecystitisIntestinal obstructionGastric cancerFunctional dyspepsiaMyocardial infarctionAbdominal angina

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Left upper quadrant (LUQ)

Colon

cancer

Colitis, irritable bowel syndromePancreatitis, pancreatic cancerSplenic

causes

Nephrolithiasis

,

hydronephrosis, pyelonephritisPulmonary causesDiaphragmatic

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Periumbilical

Enteritis

Appendicitis (early)

Pancreatitis, pancreatic cancerIntestinal obstructionAortic aneurysmAbdominal angina

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Lumbar

Kidney stone

Pyelonephritis

Perinephritic abscessColon cancer

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Right lower quadrant (RLQ)

Appendicitis

Colon cancer

Crohn’s diseaseUreterolithiasisSalpingo-oophoritis (adnexitis)

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Hypogastric - suprapubic

Cystitis

Salpingitis

Ectopic pregnancyProstatitisColonic pain

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Left lower quadrant (LLQ)

Diverticulitis

Colon cancer

Ulcerative colitisUreterolithiasisSalpingo-oophoritis (adnexitis)

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Diffuse abdominal pain

Peritonitis

Intestinal obstruction

Irritable bowel syndrome Tense ascites

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Acute abdomen

Peritonitis

Appendicitis

Bowel or gastric perforationGallbladder perforationIntestinal obstruction (ileus)Mesenterial ischaemiaExtrauterine pregnancy (ectopic pregnancy)Acute necrotising pancreatitisBiliary colicRenal colic

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History taking

Other causes abdominal pain

Diabetic ketoacidosis

HyperthyroidismAcute intermittent porphyriaHypercalcemia, hyperkalemiaVasculitisPneumoniaSickle cell crisisHerpes zoster

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Radiation of pain

Ulcer disease: to the back

Biliary pain: to the back, right scapula, right shoulder

Pancreatic: band-like, to the backKidney, ureter: to the genitalia, groinSplenic: left shoulder

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History takingSubsternal pain

Cardiac pain

Radiation: left

Type: pressing, constrictingAggravating factors: physical activity, stressRelieving factors: nitratesAssociated symptoms: dyspnoea, sweating

Esophageal pain

Radiation : back

Type:burning, spasmodic

Aggravating factors:

body position, eatingRelieving factors: antacidAssociated symptoms:dysphagia,regurgitation

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History takingDysphagia

-

difficulty in swallowing

Where is the food „hanging up”? oropharyngeal or esophagealDifficulty to swallow liquids?Progressive or constant or variable?Odynophagia- painful swallowingGlobus hystericus- feeling lump in the throat

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History takingWeight loss

Is it associated with anorexia?

Chronology

Severity (significant:> 5% of body weight)Underlying diseasesCauses: general disorders: diabetes, hyperthyroidism, chr.infections,malignancy, medications behavioral disorders: anorexia nervosa, depression

GI disorders:

malignancy, malabsorption,

hepatic, biliary, pancreatic diseases

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History takingNausea and vomiting

Organic, functional or psychogenic?

connection with meals

accompanied by weight lossContent 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

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History takingNausea and vomiting

Causes

Mechanical obstruction

DysmotilityIntraabdominal inflammations - paralytic ileusNeural causes Local - ie. diabetes, postvagotomy statesCentral neural – ie. meningitis, intracranial mass, vestibular diseasesMetabolic - hypokalemia, hypothyreoidism, pregnancy, renal failureOther

Myocardial infarction

Drugs

Psychogenic

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History takingAbdominal gas

Belching, bloating (meteorism), flatulence

Causes

Aerophagia (habitual, poor dentition, inadequate chewing, rapid eating) GI motor dysfunction or obstructionMalabsorption, maldigestionBacterial overgrowth

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History takingBowel 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/dayConstipation two or less stools/weekIncontinence

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History takingBowel movement

Stool alterations

colour

- hypocholic, acholic - pleiochromic - bloodyContent - mucus - blood

- fat - steatorrhea

- undigested proteins -

creatorrhea

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History takingBowel movement

Mechanisms of diarrhea

pathological motility

increased bowel permeabilitydecreased absorptionintraluminal osmotic factors

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History takingBowel movement

Constipation

Chronic or recent onset

CausesDecreased fluid and/or food intakeFunctional (irritable bowel syndrome)MedicationsHypothyroidismFecal impactionRectal or colon cancerChronic debilitating disease

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History takingGI bleeding

Classification

Hematemesis - fresh blood

- coffee groundMelena - blackHematochezia - blood on the stool - blood mixed with the stool

Occult bleeding

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History takingCauses of hematemesis

Fresh blood

esophageal varices

Mallory-Weiss teargross (arterial) bleeding from ulcerCoffee ground-coloured matterulcer, erosiongastro-oesophageal reflux diseaseNSAID gastropathyneoplasmsportal hypertensive gastropathy

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History takingCauses of GI bleeding

Melena

All the causes of upper GI bleeding

Sometimes from the right colon or diverticulaHematocheziaRectal diseases (hemorrhoids, fissuras, neoplasms, polyps)

Colonic diseases (neoplasms, polyps, diverticula, agiodysplasias, colitides, IBD)

Rarely from the upper GI (massive bleeding) maroon-coloured stool

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History takingJaundice

Observe

it in bright, natural lightFirst time you

can

observe

on the scleraeIn cases of dark-coloured skin:

observe: sclerae, under the

tongue, palms, solesSearch for additional symptoms:

generalised

excoriations

due

to

scratching

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History takingCauses 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 cellPosthepatic: bile duct obstruction - cholestatic jaundice

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History takingJaundice

Important anamnestic factors

Colour of the skin: overproduction: lemon-like

obstructive: dark-yellow, greenishColour of the stool: overproduction: dark, greenish (pleiochromic) obstructive: hypocholic, acholicColour of the urine: overproduction: cherry-red obstructive: dark, brownAssociated symptoms: anemia, pain, fever, hepatomegaly, splenomegaly, ascites

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History taking

Alarm

signs

in gastroenterologyPositive family

history

for

GI

malignancySignificant weight lossExtreme

diarrhoea, nightly

diarrhoeaBleedeing, anaemiaVomitusDysphagia,

odynophagia

Fever

Jaundice

Lymphadenomegaly

,

abdominal

mass

Recently

onset

symptoms

in

people

over 55

years

old

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Physical examination of the

abdomen

1.Inspection

2.Auscultation3.Percussion4. Palpation

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Position of the patient

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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 obesityAbdominal skinstriae

: white, livid (pink)

hernias

veins

:

caput Medusaevisible peristalsisvisible pulsationsscars

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Physical examinationAbdominal distension

Generalised

Obesity

PregnancyAscitesBowel obstruction - ileusBig ovarian cystPeritonitisLocalisedHepatomegaly

Splenomegaly

Polycystic kidney

Gastric distension

Inflammatory mass

TumorObstructed bladderHernia

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Physical examination

Auscultation

Bowel sounds

above the umbilicus or in the RUQnormal: 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, peritonitisSuccussion splash normal: above the stomach

pathologic: bowel obstruction

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Physical examinationPercussion

Meteorism

Liver span

midclavicular line: 6-12 cm midsternal line: 4-8 cmSplenic 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

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Ascites

shifting dullness

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Physical examinationPalpation

Position of the patient

Warm hands, short fingernails

Approach slowly, avoid quick movementsExemine tender areas at lastWatch the patient’s face

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Physical examinationPalpation

1.

Light palpation

a. muscular resistance - guarding b. alterations in the abdominal wall

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Physical examinationPalpation

2.

Deep palpation a. assessing abdominal masses b. assessing abdominal tenderness

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Physical examinationPalpation

Characteristics of an abdominal mass

1. location

2. size3. shape4. consistency5. surface6. tenderness7. movable or fixed

8. shifting by respiration

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Physical examinationPalpation of the liver and spleen

Characteristics:

1. size

2. surface3. edge4. consistency5. tenderness

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Palpation

of

the

liver

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Palpation of the spleen

1. supine position

2. right lateral position

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Physical examinationPalpation of the gallbladder

Hydrops vesicae felleae

Curvoisier’s sign -

painless enlargement of the gallbladder due to cancer of the head of the pancreasMurphy’s sign - RUQ pain aggravated by inspiration - acute cholecystitis

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Physical examinationPalpation of the aorta

to the left of the midline

normal: < 3-4 cm

>6 cm: aortic aneurysmtransmitted pulsations: pancreatic or gastric tumor, pseudocyst of the pancreas

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Physical examinationSigns of peritonitis

Guarding - defense musculaire

Pain produced by coughing

Tenderness (by palpating or percussing)Rebound tenderness

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Physical examinationPalpation of the kidneys

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Physical examinationRectal digital examination

Perianal diseases

fistulas, masses

Anal alterations hemorrhoids, fisssuras, masses Rectal alterations polyp, neoplasm, ulcerProstate glandDouglas’s spaceStool on the glove