Gastro - symptoms + signs Flashcards
Boerhaave’s syndrome symptoms + signs
- Chest pain (retrosternal, epigastric)
- Pneumomediastinum
- Shock (dyspnoea, tachypnoea, low BP, narrow pulse pressure)
- Subcutaneous emphysema
- L sided pleural effusion
Presents with chest pain, pt likely in shock (hypotension)
Mackler’s triad – classical presentation
• Chest pain
• Vomiting
• SC emphysema (air trapped in SC tissues)
Hours to days later • Pleural effusions (L side) \+/- Pneumothorax Widened mediastinum SC emphysema Hamman's sign - crunching sound upon auscultation of the heart due to pneumomediastinum
Haemorrhoids symptoms
- Bleeding (most common symptom)
- Itching
- Anal lumps
- Prolapsing tissue
- Pain
- Tenesmus
Acute Appendicitis symptoms
- Abdominal pain + vomiting
Poorly localised at the start, then localises in the RIF - Diminished BS
- Rovsing’s sign - palpation of the LIF results in greater pain in the RIF than the L
- McBurney’s sign - Percussion tenderness maximal over a point approximately 2/3 of the distance from the umbilicus laterally towards the ASIS
- Obturator sign/Cope’s sign - pain when passively internally rotating the hip
- Psoas sign - pain when passively extending the hip (represents a retrocaecal appendix)
- Dunphy’s sign - aggravation of abdominal pain by coughing
- PR - R sided tenderness
- Signs of peritonitis if perforation is present
What do the different appendicitis signs mean?
- Rovsing’s sign - LIF palpation results in RIF pain
- McBurney’s/Aaron’s sign sign - percussion tenderness maximal at a point approx 2/3 away from umblilicus towards ASIS
- Obturator sign/Cope’s sign- pain when passively internally rotating the hip
- Psoas sign - pain when passively extending the hip sign of a retrocecal appendix
- Dunphy’s sign - aggravation of abdominal pain by coughing
Perforated appendix symptoms
- Fever
- Flushed
- Tachycardic
- Peritonitis
- Diminished BS
Bowel / intestnal obstruction clinical features
- Absolute constipation + paralytic ileus – no flatus
- Diffuse Colicky abdominal pain
- Distended abdomen, tympany due to air-filled stomach
- N+V (esp in small bowel obstruction)
- Change in bowel habits – Failure to pass bowel movements
- In low level obstruction there may be a hx of progressive constipation or change in bowel habit
- Severe pain + tenderness - ischaemia or perforation
- High-pitched bowel sounds - obstruction
- Silent bowel sounds - ileus or perforation
- Abdominal mass
- Dehydration
- Empty rectum on DRE – proximal obstruction
- Soft stools on DRE – partial obstruction
- Acute abdomen with peritonism, tachycardia, fever - ?perforation
L-sided vs R-sided colon cancer
L sided - presents earlier, less advanced disease on presentation
- Early change in bowel habits
- Colicky abdominal pain
- Bowel obstruction
- Rectal bleeding
- Tenesmus
- Mass in LIF
R sided - presents later, more advanced disease at presentation
- Anaemia
- Weight loss
- Occult bleeding (bleeding not visible to the patient or the physician but it can cause iron deficiency anaemia)
- Mass in RIF
Volvulus symptoms
- Severe colicky abdominal pain + distension
- Absolute constipation - intestinal obstruction
- Hx of transient attacks in which spontaneous reduction of the volvulus has occured - relieved by passage of large amount of stool +/or flatus
- Vomiting - occurs late when destruction might be severe, leads to metabolic acidosis
Colonic perforation symptoms + signs
- Peritonitis
- Fever
- Tachycardia
- Hypotension
- Signs of dehydration
- Oliguria
- Shock
Gallstones + biliary colic symptoms + signs
- Biliary colic Constant pain RUQ May radiate around to the back in the interscapular region Increases in intensity + lasts for hours - N + V
Cholecystitis symptoms + signs
- Main difference from biliary colic is the inflammatory component
Local peritonism
Fever
Raised WCC - Intense, constant RUQ pain radiating to back, R shoulder, chest
- Distended, tender, palpable gallbladder
- Murphy’s sign
- Boas Sign- pain radiates scapula
- N+V
Acute cholangitis signs + symptoms
Charcot’s triad
- RUQ pain
- Fever
- Jaundice
Reynold’s pentad also includes
- Hypotension
- Altered mental status
- Pruritus
- Pale stools - deficient bile secretion to the small intestine
- Leukocytosis
- Abnormal LFTs
Mallory Weiss tear signs + symptoms
- Haematemesis
- Dizziness
- Postural hypotension
- Melaena
- Rockall score <3
Toxic megacolon symptoms and signs
- Large bowel dilation >6cm
- Abdominal tenderness
- Abdominal distention
- Tachycardia
- Anaemia
- Fever
- Pt acutely unwell
NON-OBSTRUCTIVE dilation of the bowel
Systemic upset
Cirrhosis symptoms + signs
- Ascites
- Peripheral oedema
- Jaundice + pruritus
- Haematemesis + melaena
- Hand + nail features Leukonychia Palmar erythmea Spider naevi Bruising Clubbing Dupuytren's contracture
- Facial features Telangiectasia Scleral icterus Spider naevi Red tongue Xanthelasma
- Abdominal features
Caput medusae
Hepatosplenomegaly
Distension - Gynaecomastia
- Loss of secondary sexual hair/testicular atrophy in men
- Muscle wasting
- Easy bruising
- Signs of portal HTN
Ascites
Caput medusae
Enlarged spleen - Signs of hepatic encephalopathy
Complications of cirrhosis
Related to the development of liver insufficiency + portal HTN
• Anaemia, thrombocytopenia, coagulopathy
Anaemia – folate deficiency, haemolysis, hypersplenism
Thrombocytopenia – 2o to hypersplenism + low levels of thrombopoietin
Coagulopathy - decreased hepatic production of coagulation factors, cholestasis causes decreased vitamin K absorption, decreased hepatic production of factors 2, 7, 9, 10
• Oesophageal varices – upper GI endoscopy
o Portal HTN
o Prophylactic abx at presentation
o Endoscopic variceal band ligation for primary prevention of bleeding
• Ascites – abdo US
o TIPS for people with cirrhosis who have refractory ascites
o May be associated with spontaneous bacterial peritonitis SPB = ascites neutrophils > 250 cells/mm3
o Spread of bacteria across the gut wall/haematogenus bacterial spread
o E. coli
- Portal HTN (causes distortion of the hepatic vasculature + can lead to increased intrahepatic resistance)
- Liver failure
- Hepatocellular carcinoma – abdo US/CT/MRI
- Jaundice
- Portosystemic encephalopathy
- AKI
- Hepatopulmonary syndromes – pulmonary arteriolar vasodilation, shunting, hypoxaemia
- Cirrhotic cardiomyopathy – cardiac hypertrophy + blunted stress response of the heart
Wernicke’s encephalopathy triad
CAN
- Confusion
- Ataxia
- Nystagmus (Opthalmoplegia)
(due to vitamin B1 deficiency)
Grade 0 hepatic encephalopathy symptoms + signs
Normal mental status
Minimal changes in memory, concentration, intellectual function, co-ordination
Grade I hepatic encephalopathy symptoms + signs
- Change in behaviour
- Mild confusion
- Slurred speech
- Euphoria or depression
- Decreased attention
- Slowing ability to perform mental tasks
- Disordered sleep
Grade 2 hepatic encephalopathy symptoms + signs
- Obvious personalty changes
- Inappropriate behaviour
- Lethargy
- Moderate confusion
- Drowsiness
Grade 3 hepatic encephalopathy symptoms + signs
- Marked cofusion (stupor)
- Unable to perform mental tasks
- Disorientation to time and place
- Occasional fits with rage
- Incoherent speech
- Sleeping but arousable
Grade 4 hepatic encephalopathy symptoms + signs
- Coma- +/- response to pain
N+V+D approx 1-6h following ingestion of contaminated dairy products or cold meat
Organism and treatment?
Staph aureus
Produces heat-stable endotoxin
Supportive treatment
V+ later D following consumption of reheated rice
Organism?
Bacillus cereus
D typically occurs 8-16h following vomiting
Abdominal pain, D, rectal bleeding following consumption of contaminated poultry
Organism and treatment?
Campylobacter
Symptoms last for approx 1-2 weeks
Erythromycin
Bloody diarrhoea witihin 1-2days of consuming contaminated meat
Organism and treatment?
E.coli
Use of abx contraindicated - may lead to toxin production
D, abdominal pain, bloody stools following contact with infected animals or ice cream
Organism and treatment?
Yersinia enterocolitica
Dx by serology
Supportive treatment
Pharyngeal pouch symptoms and signs
Cause
Epidemiology
- Dysphagia
- Halitosis
- Food getting stuck in throat
- Regurgitation
- Chronic cough
- Nocturnal cough
- Aspiration
- Weight loss
Cause - structural or functional abnormality of the cricpharyngeous
Epidemiology - most common in elderly patients
Colicky postprandial abdominal pain - what does it indicate
Chronic mesenteric/intestinal ischaemia
Peritonitis triad
Motionless patient
Tenderness and guarding on abdominal palpation
Absent BS
Describe the pain in acute pancreatitis
+ other symptoms+ signs
Sudden onset mid-epigastric/LUQ pain
Radiates to the back
Relieved by sitting forwards
• Hypovolemia
o Decreased skin turgor, dry mucous membranes, hypotension, sweating
o Tachycardic + tachypnoeic patient in more severe cases
• Increased serum [amylase]/[lipase] supports but is not pathognomonic
- Grey-Turner’s sign – indicates haemorrhagic pancreatitis
- Cullen’s sign – indicates haemorrhagic pancreatitis
Hallmark features of chronic pancreatitis
Decreased pancreatic exocrine function Malabsorption Diabetes Pancreatic calcifications loss of endocrine (diabetes) + exocrine (e.g. lipase, leading to malabsorption) secretion
Describe pain in chronic pancreatitis
+ other symptoms+ signs
Dull epigastric abdominal pain
Radiates to the back
Relieved by sitting forwards
Worse approx 30 mins after a meal
- Steatorrhea – due to injury, atrophy, loss of pancreatic exocrine tissue
- Jaundice – consider pancreatic cancer if pt presents with painless Jaundice
- N+V – non-specific
Loss of endocrine (DM) + exocrine (malabsorption) function
• DM
• Malnutrition + weight loss – fear of food due to pain, malabsorption, uncontrolled DM – consider pancreatic cancer
Signs of peritonitis
Guarding
Rebound tenderness - Blumberg sign
Fever
Sinus tachycardia
How does upper gastrointestinal bleeding present?
Coffee-ground vomiting (vomiting with partially digested blood)
Melaena (blood digested partly by HCl as opposed to haematochezia which is blood that hasn’t had time to be digested in the stomach)
Extra articular manifestations of IBD
Joints
- Inflammatory arthritis - can be various forms (polyaritcular like RA, sacroilietis lke AS)
- Eyes
Anterior uveitis
Episcleritis
Scleritis - Skin
Erythema nodosum
Pyoderma gangrenosum
Crohns Mouth ulcers Oxalate renal calculi fissures skin tags
Diverticulitis symptoms + signs
• LLQ/suprapubic abdominal pain
o Can be assosciated with a change in bowel habits
o Guarding + tenderness in LLQ
o Exacerbated by eating
o Diminished with defecation or flatus
o Generalised peritonitis if diverticulum has perforated
- Bloating, Constipation, Rectal bleeding may occur
- Anorexia, N+V
- Fever + tachycardia
- Leucocytosis
- Urinary symptoms [pneumaturia, faecaluria, recurrent UTIs] - diverticular fistulation in the bladder
- PR - pelvic tenderness, mass
- Examination: tenderness, palpable mass
Acute mesenteric ischaemia sympotms + signs
• Sudden onset diffuse abdominal pain
• Haematochezia/melaena
• Diarrhoea
• Abdominal bruit – indicates turbulent flow through an area of vascular narrowing
• Peritonism in later stages – rebound guarding, tenderness
o Suggests full thickness ischaemia, perforation or alternative diagnosis
Triad of
- Diffuse abdominal pain
- Shock signs
- Normal examination
If the physical exam demonstrates signs of peritonitis, there is likely irreversible intestinal ischemia with bowel necrosis
Chronic mesenteric ischaemia symptoms and signs
- Weight loss – usually related to sitophobia
- Colicky Postprandial abdominal pain (intestinal angina)
- Haematochezia/melaena
- Nausea, vomiting, bowel irregularity
- Normal abdominal examination
Signs of increased oestrogen in chronic liver disease
- Palmar erythema
- Gynaecomastia
- Loss of secondary sexual hair
- Testicular atrophy
Wilson’s disease symptoms + signs
• Present either with
o Hepatic disease
o Movement disorder neurological disease [copper deposition in basal ganglia]
• HEPATIC features
o Acute liver failure
o Chronic hepatitis + cirrhosis
o Fulminant hepatic failure
• BEHAVIOURAL abnormalities o Loss of control of emotions o Depression o Delusions o Loss of memory o Inability to focus on tasks o Impulsiveness o Sexual disinhibition
• NEUROLOGICAL features - MOVEMENT disorder
o Asymmetrical Tremor
o Dysarthria
o Dystonia – more common in upper extremities
o Incoordination
o Ataxia, clumsiness
o Mask-like facies
o Sloppy/small handwriting
o Dysdiadochokinesia
o Normal sensation, muscle strength, reflexes
• OPHTHALMOLOGICAL features
o Kayser-Fleischer ring [copper deposition in the descemet’s membrane – membrane between endothelial layer + stroma]
o Sunflower cataracts
o Abnormal extraocular movements – exotropic strabismus
o Night blindness
o Optic neuritis
o Optic disc pallor
• Other complications
o Hepatosplenomegaly
o Renal disease – damage to proximal tubules – Fanconi syndrome
o Haemolytic anaemia – cu damages rbc
Haemochromatosis symptoms + signs
- Fatigue
- Weakness
- Lethargy
• Arthropathy –> Arthralgias
o Calcium pyrophosphate crystal deposition
o Pseudogout
o Chronic arthropathy
iron deposits on pituitary
• Diabetes
• Hypogonadism (impotence, loss of libido, amenorrhoea)
• Heart disease
• Skin pigmentation
o May begin as bronzing of the skin but then progress to grey or brown with slate-grey patches in the mouth
• Neurological or psychiatric symptoms – impaired memory, mood swings, irritability, depression
Liver • Hepatomegaly • Fibrosis • Cirrhosis • Hepatocellular cancer
Buzzwords Fatigue, arthralgias “Bronzed skin” “Diabetes” “Hepatomegaly” MCP Arthritis
Hiaus hernia symptoms + signs
- May be asymptomatic
- Tender abdomen
- Heartburn
- Regurgitation
- Dysphagia
- Odynophagia
- Hoarseness
- Asthma
- SOB
- Chest pain
- Anaemia
- Haematemesis
Triad of hepatitis
Fever
Jaundice
Raised ALP, AST (in the 1000s apart from Hep B)
Peptic ulcer disease symptoms + signs
- Recurrent epigastric pain related to eating
- Epigastric tenderness
- Heartburn
- Early satiety
- N + V
- Potential anorexia + weight loss
- Pointing sign (patient can point to where the pain is)
duodenal more common than gastric!!
Duodenal - pain better after food, people tend to overeat and gain weight
Wakes patient at night
Gastric - pain worse after food, people tend to not eat and lose weight
signs of metastatic abdominal cancer
- Virchow’s node – Troisier’s sign
* Sister Mary Joseph node – metastatic nodule on umbilicus
Boerhaave’s perforation symptoms + signs
Presents with chest pain, pt likely in shock (hypotension)
Mackler’s triad – classical presentation
• Chest pain
• Vomiting
• SC emphysema (air trapped in SC tissues)
Hours to days later • Pleural effusions \+/- Pneumothorax Widened mediastinum SC emphysema
Sign
Hamman’s sign - crunching sound upon auscultation of the heart due to pneumomediastinum
CXR/CT - pneumomediastinum
Ruptured peptic ulcer symptoms + signs
- Coffee ground vomiting
- Melaena (usually happens prior to rupture)
- Epigastric pain
- Dyspepsia
- May be asymptomatic
- Low BP
IBS signs + symptoms
> 6 month history of abdominal pain
• Colicky
• Lower abdomen
• Relieved by defecation or flatus
Altered bowel frequency
• >3 bowel motions daily
• <3 motions weekly
- Change in stool consistency
- Passage with urgency or straining
- Tenesmus
- Bloating
- Pellet like stools – buzzword!
Coeliac disease signs + symptoms
• GI symptoms
o Diarrhoea
o Bloating
o Abdominal pain/discomfort, cramping, distension
• Malabsorption
o Calories: Failure to thrive, Weight loss
o Vitamins, minerals: osteoporosis, anaemia, neuropathy
o Fats: steatorrhoea
• Dermatitis herpetiformis (has nothing to do with the herpes virus)
What is Boas’s sign
Shoulder tip pain resulting from diaphragmatic iritation
Can be a sign of acute cholecystitis
Which artery does the cystic artery arise from?
R hepatic artery
Which of the following biochemical markers is the most specific indicator of hepatocyte damage?
Amylase ALP AST ALT Bilirubin
ALT
AST is also released by RBC, cardiac tissue, brain tissue, skeletal muscle, kidney
Features of Gilbert’s disease
Normal LFTs Normal Hb levels Serum bilirubin <100μM No bilirubin on urine dipstick Normal reticulocyte count - therefore no haemolysis
Riegler’s triad
what is it a sign of
Small bowel obstruction
Pneumobilia (air in the biliary tree)
Ectopic gallstones seen on AXR/US/CT
sign of gallstone ileus
Gallstone ileus happens as a result of formation of……
Commonest site of stone impaction….
cholecysto-duodenal fistula
ileocaecal junction
Complications of Crohn’s
- intraluminal stricture formation (string sign of Kantor)
- Intraabdominal abscess formation
- Fistula formation with the bladder, vagina
- Malabsorption
- Increased risk of bowel cancer
Hepatitis A triad
HAV
Fever
Jaundice
Malaise
but usually asymptomatic
HBV
vs
HCV
Hepatitis B
Hepatitis C
Hep B virus
• Most infections are asymptomatic
• Some will present with complications – cirrhosis, hepatocellular carcinoma, liver failure
• Some will also present with symptoms of cirrhosis + liver failure – ascites, hepatomegaly, jaundice, N+V, RUQ pain
• HBV – membranous + mesangiocapillary glomerulonephritis – does not cause haematuria
Hep C virus • Most infections are asymptomatic • Hepatic inflammation can lead to progressive hepatic fibrosis 1/3 of patients experience • Fatigue • Arthralgia • Jaundice • HCV – cryoglobulinemia-mediated glomerulonephritis – causes haematuria
- Chronic HCV is much more common than HBV
- Can cause liver fibrosis - cirrhosis - HCC
triad of haemochromatosis
bronze skin
hepatomegaly
DM
Triad of acute mesenteric ischaemia
vs chronic mesenteric ischaemia
Acute mesenteric ischaemia
Severe abdominal pain
Normal abdominal examination
Shock
Chronic mesenteric ischaemia
Poorly localised, colicky, post-prandial pain
PR bleeding
Weight loss
Budd-Chiari syndrome
Budd-Chiari syndrome = hepatic vein outflow obstruction commonly by thrombosis or malignant obstruction
Sudden onset ascites
Tender hepatomegaly
NO jaundice
Dx made by doppler scanning of the hepatic vein or venography
