Gastrointestinal

Gastrointestinal Acute Abdomen Important to determine if the patient needs urgent surgery. Note if the patient has pain relief: Usually opioid. Pain relief should not be withheld and does not affect the signs sufficiently to cause a misdiagnosis. General appearance: Distressed -> offer reassurance Vitals: Tachycardia Postural hypotension Tachypnoea Vasoconstriction Sweating Patient temperature Inspection of the abdomen Look for lack of movement with respiration with splinting of the abdomen wall muscles. If there is a history of blunt abdominal trauma look for signs of seatbelt sign -> bruising in the distribution of a seatbelt. Abdominal distension Visible peristalsis Lumps or masses Palpate Do it very gently. Firstly, assess the presence of peritonitis: Pain when the surfaces are moved relative to each other. Rebound tenderness. Ask the patient to cough Then do it more deeply. Percussion Tenderness of percussion-> do it lightly and mainly over areas of tenderness. Examine for hernias. A tender or irreducible hernias are likely to be of significance especially if the patient has recently developed tenderness. Auscultation In the presence of bowel obstructions -> more frequent and higher pitched. Ileus -> absent bowel sounds. Rectal and vaginal examination Ectopic pregnancy Urinalysis Glycosuria Ketonuria Heamaturia in renal colic Bilirubinuria in cholangitis Proteinuria in pyelonephritis Resp examination and look for signs of: Consolidation Pleural rub Pleural effusions Cardiovascular examination and look for signs of: AF -> a major cause for embolism leading to mesenteric ischemia. Back examination and look for signs of: Spinal diseases that may radiate to the abdomen. IMPORTANT NOTE: HERPES ZOSTER MAY CAUSE ABDOMINAL PAIN BEFORE THE TYPICAL VESICLES ERUPT. Look for signs of appendicitis: Malaise and fever Abdominal pain that is worse in the hypogastrium and then moves to the right iliac fossa. Pain and tenderness are maximised over McBurney’s point. Roving’s sign Psoas sign Liver disease Fever May occur in up to 1/3 of patients with advanced cirrhosis, especially secondary to alcohol or if there is infected ascites. Hands: Leukonychia Clubbing Palmar erythema Brusing Asterixis Face: Jaundice Scratch marks Spinder naevi Fetor hepaticus Chest Gynecomastia Loss of body hair Spinder naevi Brusing Pectoral muscle wasting Abdomen Hepatosplenomegaly Ascites Signs of portal hypertension Testicular atrophy Legs Edema Muscle wasting Brusing The presence of two or more of the following suggests cirrhosis: Spider naevi Palmar erythema Ascites Hepatomegaly Abnormal collateral veins on the abdomen Hepatic encephalopathy Portal hypertension Splenomegaly Collateral veins Ascites Hepatic Encephalopathy Grading Grade 0: normal mental state Grade 1: mental changes -> lack of awareness, anxiety, euphoria, reduced attention span and impaired ability to add and subtract. Grade 2: lethargy, disorientation (for time), personality changes and inappropriate behaviour. Grade 3: stupor, but responsive to stimuli, gross disorientation and confusion. Grade 4: coma May be caused by: Diarrhoea, diuretics or vomit: these may increase renal ammonia and other toxin production or alkalosis which may increase the amount of ammonia and other toxins cross the BBB. GIT bleeding or relatively high protein diet: cause an acute increase in nitrogenous content of the bowel. Infection: for example, UTI, chest or spontaneous bacteria peritonitis. Acute liver cell decomposition: from alcoholic binge or hepatoma. Sedatives Metabolic disturbances such as hypoglycaemia. Dysphagia General inspection Weight loss due to decrease food intake or oesophageal cancer. Hands Inspect the nails for koilonychia and palmar creases for pallor indicative of anaemia. Mouth Mucosa for ulcerations or infections such as candidiasis which can cause odyphagia Lower cranial nerve examination Such as evidence for pseudobulbar palsy. Neck Palpate the supraclavicular nodes which may involve an oesophageal cancer Examine for evidence of thyroid enlargement A mass on the left side of the neck that is accompanied by gurgling sounds may rarely be caused by Zenker’s diverticulum (out pouching of the posterior hypopharyngeal wall). Abdomen Feel for hepatomegaly due to secondary deposits from oesophageal cancer Feel for an epigastric mass from a gastric cancer. Perform rectal examination to exclude melena. Gastrointestinal Bleeds Hands and arms: Pulse rates Blood pressure with the patient lying and sitting down. GENERAL RULE: A BLOOD LOSS OF MORE THAN 1.5L OR MORE OF BLOOD VOLUME OVER A FEW HOURS RESULS IN REDUCED CARDIAC OUTPOUT AND HENCE HYPOTENSION. A pulse rate of more than 100 beats per minute or a fall of 15 mmHg postural fall in systolic blood pressure -> SEVERE BLOOD LOSS. The signs of depend to some extent on the status of the patient’s cardiovascular system: Patients with pre-existing cardiovascular disease will become shocked much earlier than young and fir patients with normal cardiovascular system. Shock signs once there is massive blood loss: Peripheral cyanosis -> cold extremities Clammy skin Dyspneal and air hunger Anxiety. Other important features that happen as a compensation to the low blood pressure: Tachycardia Low or absent urine output Determining the possible site of bleed: Ulcerative Colitis Abdominal signs If there is only proctitis only -> usually no abnormal external findings -> except on colonoscopy and biopsy. Anal fissures may be present Signs of complications: Toxic dilation (megacolon): Distension Guarding Rigidity -> peritonitis Pyrexia Tachycardia Massive bleeding or perforation Carcinoma Systemic signs Chronic liver disease -> cirrhosis, cholangitis Anaemia Arthritis Skin manifestations Ocular changes Crohn’s disease Abdominal signs: Tenderness Fullness Mass -> either soft or firm in the iliac fossa especially in the ileocecal junction is most often involved. Signs of abdominal abscess High fever Localised tenderness Palpable mass Evidence of bowel obstruction Pain Vomiting Constipation with dehydration Distension Tenderness Empty rectum Anal Anal disease is common Fistulas Fissures Abscess Colonic involvement Same features as ulcerative colitis Signs of complications: Osteoporosis, osteomalcaisa and bone tenderness. Signs of malabsorption Finger clubbing Signs of GIT malignancy Increase incidence of gallstones and renal stones Renal disease due to pyelonephritis, hydronephrosis or very rarely amyloidosis Malabsorption and nutritional status General: Muscle wasting -> protein and fat malabsorption. Folds of loose skin -> recent weight loss Pallor -> anaemia Pigmentation -> e.g. Whipple’s disease Stools: Glossitis Angular stomatitis -> malabsorption of vitamin B2, vitamin B6 and vitamin B12. Intraoral purpura -> vitamin K deficiency Limbs: Brusing -> vitamin K deficiency Edema -> protein deficiency Peripheral neuropathy -> vitamin B12 neuropathy Bone pain -> vitamin D deficiency Signs of underlying cause: Scars in the abdomen from pervious surgeries For example, gastrectomy, operations for CD or massive bowel resection. Dermatitis Herpetiformis: itchy red lumps on the extensor surfaces This is strongly associated with celiac disease that is associated with HLA DQ2 and HLA DQ8. Signs of chronic liver disease Signs of inflammatory bowel disease CLASSIFICATION OF MALABOSRPTIVE DISEASES Lipolytic phase defect: Pancreatic enzyme insufficiency: Chronic pancreatitis Cystic fibrosis Micellar phase defects: Bile salt deficiency: Extrahepatic biliary obstruction Chronic liver disease Bacterial overgrowth Terminal ileal disease such as Crohn’s disease or resection Mucosal defects: Diseased epithelial lining: Celiac disease Tropical sprue Lymphoma Whipple’s disease -> can cause pigmentation and arthritis Bowel ischemia or resection Amyloidosis Hypogammaglobulinemia HIV infection Delivery phase defects: Inability to transport fat of out cells into the lymphatics Intestinal lymphangiectasis Abetalipoprotienanemia Carcinomatous infiltration of the lymphatics