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PHYSICAL DIAGNOSIS EXAMINING THE GI SYSTEM. Stephen J. Goldberg, M. D. Phone: 513.686.5444. HISTORY - GETTING THE FACTS. General nutrition/appetite Swallowing/esophagus Upper GI/stomach Digestion/intestinal Elimination/colon. GENERAL NUTRITION. Stability of weight Appetite Excessive

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physical diagnosis examining the gi system

PHYSICAL DIAGNOSIS EXAMINING THE GI SYSTEM

Stephen J. Goldberg, M. D.

Phone: 513.686.5444

history getting the facts
HISTORY - GETTING THE FACTS
  • General nutrition/appetite
  • Swallowing/esophagus
  • Upper GI/stomach
  • Digestion/intestinal
  • Elimination/colon
general nutrition
GENERAL NUTRITION
  • Stability of weight
  • Appetite
    • Excessive
    • Decreased
      • Mechanical problem
      • Early satiety
      • Depression
swallowing esophagus symptoms
SWALLOWING/ESOPHAGUS - SYMPTOMS
  • Dysphagia
  • Polyphagia
  • Odynophagia
dysphagia any difficulty in swallowing
DYSPHAGIA - any difficulty in swallowing
  • Anatomical localization?
  • Solids vs liquids vs everything
  • Intermittent vs continuous
  • Associated weight loss?
  • Appetite?
polyphagia excessive eating gluttony
POLYPHAGIA - excessive eating; gluttony
  • Associated weight changes?
    • Uncontrolled diabetes
    • Malabsorption
    • Psychological problem
odynophagia painful swallowing
ODYNOPHAGIA - painful swallowing
  • Anatomical localization?
  • Intermittent vs continuous
  • Associated problems
    • Immunosuppressed
    • Weight loss
upper gi stomach symptoms
UPPER GI/STOMACH - symptoms
  • Anorexia
  • Nausea
  • Emesis
  • Hematemesis
  • Heartburn
anorexia loss of appetite
ANOREXIA - loss of appetite
  • Subjective symptom; look for objective findings
  • Duration
  • Weight loss?
  • Continuous vs intermittent
nausea inclination to vomit
NAUSEA - inclination to vomit
  • Means different things to different people
  • “Sick to stomach”
  • Subjective symptom; cannot be measured
  • Objective consequences?
    • Weight loss
  • Means of relief
emesis vomiting
EMESIS - vomiting
  • Nature of material
  • Quantity of material
  • Preceding nausea
  • Precipitating cause
  • Frequency
  • Consequences?
hematemesis vomiting blood
HEMATEMESIS - vomiting blood
  • Visible blood vs coffee-grind material
  • Implies potentially serious problem
    • Bleeding peptic ulcer
    • Gastritis
    • Esophagitis
    • Esophageal tear
    • Neoplasm
    • Bleeding esophageal varices
  • ?Antecedent events
heartburn substernal burning pyrosis
HEARTBURN - substernal burning; pyrosis
  • Due to gastro-esophageal acid reflux
  • Means different things to different people
  • Objective measures
    • Precipitating factors
    • Mode of relief
digestion intestinal symptoms
DIGESTION/INTESTINAL - symptoms
  • Indigestion/Dyspepsia
  • Belching/Eructation
  • Borgborygmi
  • Bloating/Gas/Flatulence/Distension
  • Colic
  • Steatorrhea
indigestion dyspepsia
INDIGESTION/DYSPEPSIA
  • Means different things to different people
  • INDIGESTION - failure to ?digest food properly
  • DYSPEPSIA - failure of ?stomach to ?digest food properly
  • Usually non-specific symptoms
  • Obtain precipitating factors
  • ?Mode of relief
belching eructation
BELCHING/ERUCTATION
  • Speaks for itself?
  • Forceful passage of gas from stomach thru esophagus
  • Does it signify disease or good health?
    • ?Gastroesophageal reflux
    • Rapid eating/swallowing air
    • Deliberate vs involuntary
    • ?a compliment to the chef?
  • Not to be confused with BURPING (burp = passive verb)
borborygmi audible bowel sounds
BORBORYGMI - audible bowel sounds
  • Rumbling or gurgling of intestinal contents
  • ?Significance
bloating gas flatulence distension
BLOATING/GAS/FLATULENCE/DISTENSION
  • Subjective vs objective symptoms
  • Depends on where the gas is and what it’s doing
  • May be a sign of disease
    • Malabsorption
    • Bacterial overgrowth
    • Obstruction
  • May be innocuous
    • Irritable bowel syndrome
    • Overeating
colic spasmodic abdominal pain
COLIC - spasmodic abdominal pain
  • Crescendo/decrescendo pattern
  • Visceral origin
  • May be anatomical or functional in origin
    • ANATOMICAL = obstruction
    • FUNCTION = erratic peristalsis
steatorrhea passage of fatty stools
STEATORRHEA - passage of fatty stools
  • Difficult to document or quantify by history
  • May indicate fat malabsorption
  • Stools do not have to be loose to have increased fat
elimination colon symptoms
ELIMINATION/COLON - symptoms
  • Diarrhea
  • Constipation
  • Scybyla
  • Hematochezia
  • Melena
  • Tenesmus
  • Hemorrhoids
diarrhea stool with increased liquid content
DIARRHEA - stool with increased liquid content
  • May be increased in frequency
  • May represent disease (increased secretion)
  • May represent pharmacologic effect (osmotic action)
  • May represent rapid peristalsis and inefficient fluid regulation (irritable bowel syndrome)
  • IS IT A CHANGE?
  • IS IT ASSOCIATED WITH ANYTHING BAD?
constipation having stool which is difficult to pass
CONSTIPATION - having stool which is difficult to pass
  • May be decreased in frequency
  • May be harder (drier) than expected
  • May be smaller than expected
  • May be associated with discomfort from any of the above
  • Usually markedly decreased water content
  • IS IT A CHANGE?
  • IS IT ASSOCIATED WITH ANYTHING BAD?
scybala small hard round masses of stool
SCYBALA - small, hard, round masses of stool
  • Handy medical term with little significance
hematochezia passage of stool with fresh blood
HEMATOCHEZIA - passage of stool with fresh blood
  • Blood is visible, not occult
  • Explanation is mandatory
  • Most commonly from hemorrhoids
  • Most frequently associated with constipation
  • May be an early sign of colon cancer
melena passage of stool which is black from digested blood
MELENA - passage of stool which is black from digested blood
  • Characteristic color and odor
  • Signifies digested blood from UGI origin
  • Signifies a significant blood loss
tensemus rectal pain
TENSEMUS - rectal pain
  • Suggests proctitis
    • Infection
    • Inflammatory bowel disease
  • May be due to spasm (irritable bowel syndrome)
hemorrhoids anal varicosities
HEMORRHOIDS - anal varicosities
  • Also known as “piles”
  • “Internal”
    • Not palpable
    • Bleed
    • May prolapse
    • Usually no discomfort
  • “External”
    • Visible
    • Painful at times
evaluating gi symptoms 1
Precipitating factors

Relation to meals

Time of day

Position

?Predictability

?Explainable on a physiologic basis

Localization

LLQ-->sigmoid,gyn

RLQ-->terminal ileum, gyn, appendix, sigmoid?

LUQ-->splenic flexure, ?pancreas

Epigastric--> stomach, pancreas

RUQ-->liver, gall bladder, duodenum

EVALUATING GI SYMPTOMS-1
evaluating gi symptoms 2
Symptom duration

Continuous--> pancreatitis?

Post-prandial--> mal-digestion? acid? obstruction?

Wax/wane--> visceral?

Symptom relief

Eating --> acid neutralization

Position - ->sedation, pancreatitis?

Passage of flatus --> colonic distension?

Bowel movement--> colonic distension?  peristalsis?

EVALUATING GI SYMPTOMS-2
additional historical information
Weight loss?

Family history

Carcinoma

Peptic ulcer disease

Gallstones

Inflammatory bowel disease

Cirrhosis

Abdominal surgery

Travel history

Military history

Lifestyle

Alcohol

Substance abuse

Sexually transmitted diseases (STD)

Medications

Uses

Adverse effects

ADDITIONAL HISTORICAL INFORMATION
physical exam 1
TERMS

Striae - stripe or line in skin distinguished by color or texture

Scaphoid - concave

Tympany- resonant sound

Bruit - “abnormal vascular sound heard on auscultation”

TERMS

Fissure - break or slit in tissue

Fistula - abnormal passage between two organs or structures, permitting passage of fluids or secretions

PHYSICAL EXAM 1
physical exam 2 the basics
LANDMARKS

Costal margin

Xiphoid process

Pubic tubercle

Inguinal ligament

Anterior superior iliac spine

Iliac crest

Umbilicus

LANDMARKS

Quadrants

RUQ, LUQ

RLQ, LLQ

Ninths

Epigastrium (2)

Peri-umbilical (5)

Hypogastrium (8)

SEQUENCE

Inspection  Auscultation  Percussion  Palpation

PHYSICAL EXAM 2The Basics
physical exam 2 prerequisites for examination
PHYSICAL EXAM 2Prerequisites for examination
  • Patient should have empty bladder
  • Patient should be supine
  • Examiner should be to right of patient
  • Examiner should be prepared to explain each step of examination
  • Examiner should be watching patient for signs of discomfort
physical exam 3
PHYSICAL EXAM 3
  • INSPECTION
    • SYMMETRY
    • CONTOUR
      • Flat
      • Scaphoid
      • Protuberant
    • SKIN
    • MASSES
    • PULSATIONS, PERISTALSIS
physical exam 4
PHYSICAL EXAM 4
  • AUSCULTATION
    • Bowel sounds

?Normal, ?Increased, ?Decreased, ?Absent

    • Bruits
      • Renal
      • Hepatic
      • Iliac
      • Femoral
physical exam 5
PHYSICAL EXAM 5
  • PERCUSSION
    • Liver span – percuss downward from chest, upward from abdomen
      • Normal span 6-12 cm
    • Stomach, bowel gas
    • Masses
    • Ascites
    • Spleen?
ascites intraperitoneal fluid
ASCITESIntraperitoneal fluid
  • Fluid wave
  • Ballottment
  • Contour
  • Shifting dullness

Percuss abdomen to outline dullness/tympany

Have patient roll away from you

Percuss again to outline dullness/tympany

If dullness has shifted to areas of prior tympany, ascites may be present

physical exam 6
PHYSICAL EXAM 6
  • PALPATION
    • Liver
    • Spleen
    • Tenderness/rebound
    • Sigmoid
    • ?Cecum
    • ?Aorta
    • ?Kidney
    • ?Gall bladder
palpating the liver
PALPATING THE LIVER
  • Standard method
    • Stand facing patient and place fingers below right costal margin and press firmly
    • Have patient take a deep breath
  • Alternate method
    • Stand beside patient’s chest and hook fingers just below right costal margin
    • Have patient take a deep breath

NORMAL LIVER SPAN = 6-12 CM AT RIGHT MID-CLAVICULAR LINE

palpating the spleen
PALPATING THE SPLEEN
  • The patient lies in the supine position
  • The examiner uses left hand to lift left lower rib cage
  • The examiner exerts pressure with right hand just below left costal margin
  • The patient takes a deep breath

THE SPLEEN IS NOT NORMALLY PALABLE IN ADULTS

rebound tenderness detects peritoneal irritation
REBOUND TENDERNESSDetects peritoneal irritation
  • Examiner presses deeply on abdomen
  • Examiner quickly releases pressure after a moment
  • If sudden release of examining hand  pain, then rebound tenderness is present  peritoneal irritation
palpable gall bladder
PALPABLE GALL BLADDER?
  • Courvoisier’s sign
    • Palpable gall bladder, no jaundice ==> cystic duct stone
    • Palpable gall bladder, jaundice ==> carcinoma
    • Non-palpable gall bladder, jaundice ==> common duct stone(s)
manifestations of chronic liver disease
Jaundice

Spider angiomata

Palmar erythema

Gynecomastia

Ascites

Asterixis

Signs of portal hypertension

Feminization of truncal hair pattern

?Parotid enlargement

?Testicular atrophy

MANIFESTATIONS OFCHRONIC LIVER DISEASE
anorectal examination
ANORECTAL EXAMINATION
  • External hemorrhoids
  • Anal tone
  • Warts
  • Tenderness
  • Prostate
  • Polyps/rectal masses
  • Stool for occult blood exam (HEMOCCULT)
nutritional status
NUTRITIONAL STATUS
  • General Appearance
  • Muscle mass
  • Skin turgor/redundancy/striae
  • Skin-fold thickness
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