Gastrointestinal Examination Flashcards
Causes of gum hypertrophy
- Phenytoin
- Pregnancy
- Scurvy (vitamin C deficiency: the gums become spongy, red, bleed easily and are swollen and irregular)
- Gingivitis, e.g. from smoking, calculus, plaque, Vincent’s angina (fusobacterial membranous tonsillitis)
- Leukaemia (usually monocytic)
Causes of pigmented lesions in the mouth
- Heavy metals: lead or bismuth (blue-black line on the gingival margin), iron (haemochromatosis— blue-grey pigmentation of the hard palate)
- Drugs: antimalarials, the oral contraceptive pill (brown or black areas of pigmentation anywhere in the mouth)
- Addison’s disease (blotches of dark brown pigment anywhere in the mouth)
- Peutz-Jeghers syndrome (lips, buccal mucosa or palate)
- Malignant melanoma (raised, painless black lesions anywhere in the mouth)
Causes of fetor (bad breath)
- Faulty oral hygiene
- Fetor hepaticus (a sweet smell)
- Ketosis (diabetic ketoacidosis results in excretion of ketones in exhaled air, causing a sickly sweet smell)
- Uraemia (fish breath: an ammoniacal odour)
- Alcohol (distinctive)
- Paraldehyde
- Putrid (due to anaerobic chest infections with large amounts of sputum)
- Cigarettes
Causes of mouth ulcers
Common
- Aphthous
- Trauma
- Drugs (e.g. gold, steroids)
Uncommon
- Gastrointestinal disease: Crohn’s disease, ulcerative colitis, coeliac disease
- Rheumatological disease: Behçet’s* syndrome, Reiter’s† syndrome
- Erythema multiforme
- Infection: viral—herpes zoster, herpes simplex; bacterial—syphilis (primary chancre, secondary snail track ulcers, mucous patches), tuberculosis
- Self-inflicted
Causes of parotid enlargement
Bilateral
- Mumps (can be unilateral)
- Sarcoidosis or lymphoma, which may cause painless bilateral enlargement
- Mikulicz syndrome: bilateral painless enlargement of all three salivary glands; this disease is probably an early stage of Sjögren’s syndrome
- Alcohol-associated parotiditis
- Malnutrition
- Severe dehydration: as occurs in renal failure, terminal carcinomatosis and severe infections
Unilateral
- Mixed parotid tumour (occasionally bilateral)
- Tumour infiltration, which usually causes painless unilateral enlargement and may cause facial nerve palsy
- Duct blockage (e.g. salivary calculus)
Differential diagnosis in liver palpation
Hepatomegaly
Firm and Irregular Liver
Tender Liver
Pulsatile Liver
Hepatomegaly
Massive
• Metastases
• Alcoholic liver disease with fatty infiltration
• Myeloproliferative disease
• Right heart failure
• Hepatocellular cancer
Moderate
• The above causes
• Haemochromatosis
• Haematological disease (e.g. chronic leukaemia, lymphoma)
• Fatty liver (secondary to e.g. diabetes mellitus, obesity, toxins)
• Infiltration (e.g. amyloid)
Mild
• The above causes
• Hepatitis
• Biliary obstruction
• Hydatid disease
• Human immunodeficiency virus (HIV) infection
Firm and irregular liver
Hepatocellular carcinoma
Metastatic disease
Cirrhosis
Hydatid disease, granuloma (e.g. sarcoid), amyloid, cysts, lipoidoses
Tender liver
Hepatitis
Rapid liver enlargement (e.g. right heart failure, Budd-Chiari* syndrome [hepatic vein thrombosis])
Hepatocellular cancer
Hepatic abscess
Biliary obstruction cholangitis
Pulsatile liver
Tricuspid regurgitation
Hepatocellular cancer
Vascular abnormalities
Gallbladder enlargement with jaundice
With jaundice
- Carcinoma of the head of the pancreas
- Carcinoma of the ampulla of Vater*
- In-situ gallstone formation in the common bile duct
- Mucocele of the gallbladder due to a stone in Hartmann’s pouch and a stone in the common bile duct (very rare)
Without jaundice
- Mucocele or empyema of the gallbladder • Carcinoma of the gallbladder (stone hard, irregular swelling)
- Acute cholecystitis
Causes of hepatosplenomegaly
- Chronic liver disease with portal hypertension
- Haematological disease (e.g. myeloproliferative disease, lymphoma, leukaemia, pernicious anaemia, sickle cell anaemia)
- Infection (e.g. acute viral hepatitis, infectious mononucleosis, cytomegalovirus)
- Infiltration (e.g. amyloid, sarcoid)
- Connective tissue disease (e.g. systemic lupus erythematosus)
- Acromegaly
- Thyrotoxicosis
Causes of abdominal masses
Right iliac fossa
Appendiceal abscess or mucocele of the appendix
Carcinoma of the caecum or caecal distension due to distal obstruction
Crohn’s disease (usually when complicated by an abscess)
Ovarian tumour or cyst
Hernia
Transplanted kidney
Left iliac fossa
Faeces (note: can often be indented)
Carcinoma of sigmoid or descending colon
Ovarian tumour or cyst
Psoas abscess
Hernia
Transplanted kidney
Upper abdomen
Retroperitoneal lymphadenopathy (e.g. lymphoma, teratoma)
Left lobe of the liver
Abdominal aortic aneurysm (expansile)
Carcinoma of the stomach
Pancreatic pseudocyst or tumour
Gastric dilation (e.g. pyloric stenosis, acute dilation in diabetic ketoacidosis or after surgery)
Pelvis
Bladder
Ovarian tumour or cyst
Uterus (e.g. pregnancy, tumour, fibroids)
Small bowel obstruction
Some causes of anterior abdominal wall masses
Lipoma
Sebaceous cyst
Dermal fibroma
Malignant deposits (e.g. melanoma, carcinoma)
Epigastric hernia
Umbilical or paraumbilical hernia
Incisional hernia
Rectus sheath divarication
Rectus sheath haematoma
Differential diagnosis of a solitary groin lump
Above the inguinal ligament
Inguinal hernia
Undescended testis
Cyst of the canal of Nuck
Encysted hydrocele or lipoma of the cord Iliac node
Below the inguinal ligament
Femoral hernia
Lymph node
Saphena varix (sensation of a ‘jet of water’ on palpation, disappears when supine)
Femoral aneurysm (pulsatile)
Psoas abscess (associated with fever, flank pain and flexion deformity)
Porphyria Cutanea Tarda
Fragile vesicles on exposed areas of the skin and heal with scarring . Urine is dark in this chronic disorder of porphyrin metabolism associated with alcoholism and hepatitis C.
Peutz-Jeghers syndrome
Freckle-like spots (discrete, brown-black lesions) around the mouth and on the buccal mucosa and on the fingers and toes are associated with hamartomas of the small bowel (50%) and colon (30%), which can present with bleeding or intussusception. In this autosomal dominant condition the incidence of gastrointestinal adenocarcinoma is increased.
Acanthosis nigricans
These are brown-to-black velvety elevations of the epidermis due to confluent papillomas and are usually found in the axillae and nape of the neck. Acanthosis nigricans is associated rarely with gastrointestinal carcinoma (particularly stomach) and lymphoma, as well as with acromegaly, diabetes mellitus and other endocrinopathies.
Haemochromatosis
Haemosiderin stimulates melanocytes to produce melanin - bronze skin
Associated with hepatomegaly and signs of chronic liver disease as well as diabetes mellitus, heart failure (cardiomyopathy), arthropathy, testicular atrophy
Hereditary haemorrhagic telangiectasia
(Rendu-Osler-Weber syndrome)
Multiple small telangiectasias occur in this disease. They are often present on the lips and tongue, but may be found anywhere on the skin. When they are present in the gastrointestinal tract they can cause chronic blood loss or even, occasionally, torrential bleeding. Associated arteriovenous malformations may occur. This is an autosomal dominant condition and is uncommon.
Kayser-Fleischer rings
Brownish-green rings occurring at the periphery of the cornea, affecting the upper pole more than the lower. They are due to deposits of excess copper in Descemet’s membranek of the cornea. Slit-lamp examination is often necessary to show them. They are typically found in Wilson’s disease, a copper storage disease that causes cirrhosis and neurological disturbances. Kayser-Fleischer rings are usually present by the time neurological signs have appeared. Patients with other cholestatic liver diseases, however, can also have these rings. Iritis may be seen in inflammatory bowel disease
Bitot spot
Bitot’s spots are yellow keratinised areas on the sclera. They are the result of severe vitamin A deficiency due to malabsorption or malnutrition. Retinal damage and blindness may occur as a later development.
Xanthelasmata
Yellowish plaques in the sub-cutaneous tissues in the periorbital region due to deposits of lipids. They may indicate protracted elevation of the serum cholesterol. In patients with cholestasis, an abnormal lipoprotein (lipoprotein X) is found in the plasma and is associated with elevation of the serum cholesterol. Xanthelasmata are common in patients with primary biliary cirrhosis.
Grey–Turner’s sign
Skin discolouration in the flanks occuring in severe cases of acute pancreatitis or retroperitoneal bleed
Cullen’s sign
Discolouration of the umbilicus where a faintly bluish hue is present is found rarely, in cases of extensive haemoperitoneum (retroperitoneal bleed) and acute pancreatitis.
Regions of the abdomen
