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GI complaints

Common signs & symptoms


Abdominal Pain
 Common

 What is causing it?

 Life-threatening?
Acute Abdomen

Sudden onset of abdominal pain


Indicates peritoneal irritation
Anatomy
 Gastrointestinal System Look it Up!

 Renal or Urinary System

 Reproductive System

Male
 Female
The Abdomen (2 of 2)
Description of Abdominal Pain
 Local
 General or diffuse
 Referred
 Colic
Ulcer
 Erosion of the stomach or intestinal lining.

 Epigastric or abdominal pain


 Hematemesis – blood in emesis

Bright red

Coffe ground
Hernia
 Protrusion of tissue through body wall

 pain
 red or blue skin discoloration
 incarcerated
 can be serious medical emergency
Esophageal Varices
 enlarged blood vessels in the esophagus
that can rupture

 massive bright red bleeding (oral)


 Shock
Hx of liver disease or ETOH abuse
Bowel Obstruction
 A blockage of the bowel lumen prohibiting
the passage of material

 Hx of recent abdominal surgery



constipation

colicky abdominal pain
 abdominal distention
 Nausea/Vomiting
Appendicitis
 Inflammation of the appendix

fever
anorexia
N/V
RLQ pain
Rebound tenderness
Cholecystitis
 Inflammation of the gallbladder


Gallstones?
 recent ingestion of fatty food?
 RUQ pain

gradual onset
 not colicky pain
Kidney Stones
 Calculi in the kidney


severe flank pain
 maybe colicky
 restlessness

nausea & vomiting
Urinary Tract Infection (UTI)
 Bacterial infection in the urinary tract

 Lower abdominal pain


 Pain and/or burning with urination
 Hematuria
 Urgency and frequency
Pyelonephritis
 Inflammation of the kidney


Flank pain
 Pain and/or burning with urination
 Hematuria

Fever
Pelvic Inflammatory Disease
 The inflammation of the female pelvic
organs (STD)

Dull RLQ or LLQ pain


abnormal vaginal discharge
nausea & vomiting
fever
Ectopic Pregnancy
 Embryo gestation outside uterus (usually
fallopian tube)

RLQ or LLQ pain


late LMP
may have vaginal bleeding
shock
Peritonitis
Inflammation of the peritoneum

Generalized abdominal pain


Fever
Rigid abdomen
Nausea and/or vomiting
Distention
Dissecting Abdominal Aortic
Aneurysm
 Aneurysm develops between arterial
layers

shearing/tearing abdominal pain


sudden onset
shock
unequal femoral pulses
Assessment
 OPQRST - all pain is not the same
 SAMPLE or HAM

 nausea, vomiting, diarrhea


 anorexia


fever

weakness or syncope
The physical exam
 observe for distention
 palpate for TRPGR
 check all 4 quadrants
 start away from pain
Females
 Always consider a gynecological problem
with women having abdominal pain

 Pregnant?

LMP
 Normal?
 Prior gynecological problems
Notes

 nasogastric tubes (NG tubes)


 gastrointestinal tube (GI tubes)
 colostomy / illeostomy
GI Bleeding
 Pain
 “heartburn”
 Signs of shock
 And the following types of bleeding
Bright red rectal bleeding
 indicates bleed close to anus.

 obvious sign ( not subtle )


 minor bleeds usually hemorrhoid
Melena
 Dark, tar-like stools
 Lower GI bleed

Can be only indication of GI bleed

can represent significant blood loss


Coffee ground emesis
 Partially digested blood


chronic
 stomach or duodenum
Bright red emesis
 upper Gi bleed
 above stomach

 Think Esophageal varices


 Can be severe
Hemorrhoid
Enlarged blood vessels near the anus.

Rectal pain
bleeding
Examination of Abdomen
Position of the patient: the patient should lie flat, with one pillow under the head in
order to relax the muscles of abdominal wall.

Exposure: abdomen should be exposed from xiphisternum to the pubis.

• Inspection:

Shape of abdomen:
• Normally full
• Scaphoid: a sunken abdomen due to starvation or wasting disease
• Protuberant: due to fat (gross obesity), fetus (pregnancy), flatus (gaseous
distension due to intestinal obstruction), fluid (ascites).
Symmetry:
• Normally symmetrical
• Asymmetry due to visible bulge due to hepatic, splenic and kidney enlargement
or a tumour. Bulging may be central due to uterus, bladder or ovary enlargement.
Movements:
•Normally moving equally with respiration
•Respiratory movement of the abdomen usually cease in the presence of acute
peritonitis.

Umbilicus:
•normally central and inverted
•Placed upward due to pregnancy and huge ovarian cyst
•Flat or everted due to ascites.

Prominent veins:
•Collateral veins visible due to IVC obstruction due to tumour or thrombosis, the
direction of flow is upwards towards heart.
•Collateral veins due to cirrhosis radiate from umbilicus forming Caput Medusa,
the direction of flow is downwards towards the leg below the umbilicus.
Skin:
•Look for previous surgical scars, striae and pigmentations
•Striae may be due to pregnancy, ascites, recent weight loss and Cushing’s
syndrome.
Pulsations:
•Usually transmitted from the abdominal aorta
•Less frequently caused by right ventricle, the liver or an abdominal aneurysm.

Peristalsis:
•Prominent in small intestinal obstruction
•May be visible as slow way of movement passing across the upper abdomen
from left to right in pyloric stenosis
•They may be present normally.

Hernias:
•Look for incisional, epigastric, umbilical, femoral and inguinal hernias.

Inspection of abdomen at eye level:

Squat down beside the bed so that the patient’s abdomen is at eye level, ask him to
take slow and deep breaths through mouth and watch for any evidence of
asymmetrical movement, indicating the presence of mass such as enlarged liver
and spleen.
2. Palpation:

General principles:
• Ensure that the examining hands are warm.
• If patient is in a low bed, sit on, or kneel beside, the bed.
• Ask the patient if any particular area is tender and examine this area last.
• Encourage the patient to breath gently through the mouth.
• If necessary, ask the patient to bend the knees to relax the abdominal
muscles.

Palpation can be divided into three phases:


5. Light
6. Deep and during
7. Inspiration

Light palpation:

Object: to note tenderness, guarding, rigidity and lump.

Method:
• Place the examining hand on the abdomen and thereafter maintain
continuous contact with the patient’s abdominal wall.
• Note the tenderness and lumps in each region.
Deep palpation:

Object: to detect deeper masses and to define those already discovered.

Method:
• palpate the abdomen with the flat of the hand. If a mass is discovered
describe its characteristics such as,
• Site, size, tenderness.
• Surface which may be regular or irregular.
• Edges: regular/irregular
• Consistency: hard/soft.
• Mobility and movement with inspiration.
• Pulsatile or not.
• Whether one can get above the mass.

Palpation during inspiration:

The liver, spleen, kidney and gall bladder should be examined during inspiration.

The key success in visceral palpation is to keep the examining hand still and wait
for the organ’s edge to descend and strike during inspiration.
How to palpate liver?
• Place the hand flat on the abdomen with the fingers pointing upwards and
position the sensing fingers (middle and index) lateral to the rectus muscle.

• Press the hand firmly inward and upward and keep steady while the patient
takes a breath through the mouth.

• If the liver edge is palpable describe its character such as sharp or round, hard
or soft, regular or irregular and non-tender or tender.

• Causes of tender hepatomegaly are hepatitis, liver abscess and congestion due
to right heart failure.
Measuring Liver Span

Percuss from the fourth intercostal space downward and mark


the upper border of liver identified when percussion note
becomes dull from resonant, usually at the level of sixth rib.
Now percuss from right iliac fossa upwards and mark the level
where the lower border of liver is palpable. Measure this span
that is usually less than 12.5cm. Span increases in
hepatomegaly and decreases in cirrhosis.

Liver may be palpable without hepatomegaly due to


downward descent due to hyperinflation of lung in asthma and
COPD.
How to measure spleen?
• Place the examining hand on the anterior abdominal wall with the fingertips
well below the left costal margin, pressing inwards and upwards.

• Ask the patient to take deep breath, if spleen is enlarged it will hit the fingers
during inspiration.

• If the spleen is not palpable, the patient must be rolled on the right side
towards the examiner with left hip and knee flexed and palpation is repeated
with the right hand while the left hand of examiner compressing left lower
costal margin downwards.

• If spleen is still not palpable examine the patient from the left side, curling the
fingers of the examining hand under the left costal margin as the patient
breathes in deeply.

• Spleen can be palpated by hooking method while standing on the left side of
the patient.
How to measure kidney?
• Use a bimanual technique to palpate the kidneys.

• Place one hand posteriorly below the lower rib cage and the other over the
upper quadrant anteriorly.

• Push both hands together firmly and feel the lower pole moving down between
hands as the patient breathes in deeply.

• Push kidney back and forwards between the two hands- this is known as
balloting.

• Assess the size, surface and consistency of palpable kidney.

• Examine the left kidney.


1. Percussion:

Object:
• To differentiate between abdominal distension due to ascites, gas, cystic or
solid tumour.
• To define the size and nature of organs and masses.

General principles:
• Percuss from resonant to dull area.
• Percuss the upper border of liver, and then measure the liver span.

Thrill:
To detect the thrill, place a detecting hand on the patient’s flank; flick the skin of the
abdominal wall over the other flank using the forefinger.

Shifting dullness:
• Percussion should be started in the midline (with the fingers pointing towards
the feet) then continue percussion towards the flanks until a dull note is
obtained.
• Keep the finger in place as the patient rolls to the other side.
• Pause for about 10seconds and percuss again. Ascites is suggested if the note
becomes resonant and confirmed by obtaining a dull note while percussing
back towards the umbilicus.
4. Auscultation:

• Place the diaphragm of stethoscope just below the umbilicus and ascultate for
peristalsis bowel sounds for at least 3 minutes before deciding that they are
absent (i.e. paralytic ileus)

• Auscultate liver for bruit present in hepatoma.

• Auscultate for renal bruit on either side of midline above the umbilicus, it may
be present in renal artery stenosis.

• Auscultate over the aorta for bruit.

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