Examination of gastrointestinal system by HX

1. Gastrointestinal System Examination Surface markings Liver upper border 5 th 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 12 th rib posteriorly , 7 cm from the midline, the right is 2-3 cm lower than the left. 1 zaw aung

2. Abdomen can be divided into nine regions by the zaw aung 2

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. Symptoms and definitions General Anorexia  loss of appetite Weight loss  significant >3 kg in 6 months zaw aung 4

5. Upper GI Dysphagi a Difficulty in swallowing Ask for Is dysphagia painful or painless Is dysphagia intermittent or progressive How long Is there a previous history of dysphagia or heartburn. Is the dysphagia for solids or liquids or both What level does food stick Is there complete obstruction with food regurgitation. zaw aung 5

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. 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. 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. 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, hepatitis Non-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. 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. 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. Abdominal distension Causes fat obese Flatus obstruction, pseudo-obstruction Faeces obstruction, constipation Fluid ascites, tumours, distended bladder Fetus Functional bloating zaw aung 12

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. 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. 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. 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. Always investigate alarms symptoms particularly those over >50 years. zaw aung 17

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. Drug History Prescribed medications, over-the-counter medications, herbal preparations and indigenous medicines. zaw aung 19

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. 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. 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. hands Clubbing Koilonychia Signs of liver disease – leukonychia - palmer erythema - flapping tremors - zaw aung 23

24. face Pallor Jaundice Spider naevi Parotid swelling Mouth- angular stomatitis , glossitis , teeth and gums Neck goitre , neck glands zaw aung 24

25. Legs Oedema Pyoderma gangrenosum zaw aung 25

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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. 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. 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

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