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Examination of gastrointestinal system by HX
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. ⢠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 adjectivesâsharp/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 ď loss of appetite
⢠Weight loss ď significant >3 kg in 6 months
zaw aung 4
5. Upper GI
⢠Dysphagia
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
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 ďĄ 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
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
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
Crohnâs disease or ulcerative colitis.
⢠Colorectal cancer in a first degree relative
increase the risk of colorectal cancer and
polyps.
⢠PU is familial.
⢠Gilbertâs disease, haemochromatosis, Wilsonâs
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 patientâs 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
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