Gastrointestinal history and examination Flashcards
Gastrointestinal history: presenting symptoms
Abdominal pain. Distension. Nausea, vomiting, haematemesis. Dysphagia. Indigestion/dyspepsia/reflux. Recent change in bowel habit. Diarrhoea, constipation. Rectal bleeding or melaena. Appetite, weight change. Jaundice.
Gastrointestinal history: What direct questions should you ask someone presenting with abdominal pain?
SOCRATES.
Gastrointestinal history: What direct questions should you ask someone presenting with nausea/vomiting?
Timing? Relation to meals? Amount? Content? e.g. liquid, solid, bile, blood. Frequency?
Gastrointestinal history: What direct questions should you ask someone presenting with haematemesis?
Timing? Relation to meals? Amount? Frequency? Fresh (bright red)/dark/coffee grounds? Consider neoplasia- weight loss? dysphagia? pain? melaena? NSAIDs/warfarin? Surgery? Smoking?
Gastrointestinal history: What direct questions should you ask someone presenting with dysphagia?
Level? Onset? Intermittent? Progressive? Painful swallow (odynophagia)?
Gastrointestinal history: What direct questions should you ask someone presenting with indigestion/dyspepsia/reflux?
Timing?
Relation to meals?
Gastrointestinal history: What direct questions should you ask someone presenting with recent change in bowel habit?
Consider neoplasia- weight loss? dysphagia? pain? melaena?
Gastrointestinal history: What direct questions should you ask someone presenting with rectal bleeding or melaena?
Pain on defaecation?
Mucus?
Fresh/dark/black?
Mixed with stool/on surface/on paper/in the pan?
Gastrointestinal history: What direct questions should you ask someone presenting with appetite/weight change?
Intentional?
Quantify.
Dysphagia?
Pain?
Gastrointestinal history: What direct questions should you ask someone presenting with jaundice?
Pruritic?
Dark urine?
Pale stools?
Gastrointestinal history: past medical history
Peptic ulcer disease. Carcinoma. Jaundice. Hepatitis. Blood transfusions. Tattoos. Previous operations. Last menstrual period (LMP). Dietary changes.
Gastrointestinal history: drug history
Steroids.
NSAIDs.
Antibiotics.
Anticoagulants, e.g. clopidogrel with SSRI.
Gastrointestinal history: family history
IBS. IBD. PUD. Polyps. Cancer. Jaundice.
Gastrointestinal history: social history
Smoking. Alcohol (quantify units/week). Recreational drug use. Travel history. Tropical illnesses. Contact with jaundiced persons. Occupational exposures. Sexual history. Blood transfusions. Surgery overseas.
Gastrointestinal history: causes of vomiting, GI
Gastroenteritis. Peptic ulceration. Pyloric stenosis. Intestinal obstruction. Paralytic ileus. Acute cholecystitis. Acute pancreatitis.
Gastrointestinal history: causes of vomiting, CNS
Meningitis/encephalitis. Migraine. Raised intracranial pressure. Brainstem lesions. Motion sickness. Meniere's disease. Labyrinthitis.
Gastrointestinal history: causes of vomiting, metabolic/endocrine
Uraemia. Hypercalcaemia. Hyponatraemia. Pregnancy. Diabetic ketoacidosis. Addison's disease.
Gastrointestinal history: causes of vomiting, drugs
Antibiotics. Opiates. Cytotoxics. Digoxin. Alcohol.
Gastrointestinal history: causes of vomiting, psychiatric
Self-induced.
Psychogenic.
Bulimia nervosa.
Gastrointestinal history: causes of vomiting, others
Myocardial infarction.
Autonomic neuropathy.
Sepsis (UTI, meningitis).
Gastrointestinal history: causes of epigastric pain
Pancreatitis. Gastritis/duodenitis. Peptic ulcer. Gallbladder disease. Aortic aneurysm. Referred pain from MI or pleural pathology.
Gastrointestinal history: causes of LUQ pain
Peptic ulcer. Gastric or colonic (splenic flexure) cancer. Splenic rupture. Subphrenic or perinephric abscess. Renal (colic, pyelonephritis).
Gastrointestinal history: causes of RUQ pain
Cholecystitis. Biliary colic. Hepatitis. Peptic ulcer. Colonic cancer (hepatic flexure). Renal (colic, pyelonephritis). Subphrenic/perinephric abscess.
Gastrointestinal history: causes of loin pain
Renal colic. Pyelonephritis. Renal tumour. Perinephric abscess. Pain referred from vertebral column.
Gastrointestinal history: causes of LIF pain
Diverticulitis. Volvulus. Colon cancer. Pelvic abscess. Inflammatory bowel disease. Hip pathology. Renal colic. UTI. Cancer in undescended testes. Zoster- wait for rash. Gynae: torsion of ovarian cyst, salpingitis, ectopic pregnancy.
Gastrointestinal history: causes of RIF pain
Appendicitis. Crohn's ileitis. Volvulus. Colon cancer. Pelvic abscess. Inflammatory bowel disease. Hip pathology. Renal colic. UTI. Cancer in undescended testes. Zoster- wait for rash. Gynae: torsion of ovarian cyst, salpingitis, ectopic pregnancy.
Gastrointestinal history: causes of pelvic pain
Urological: UTI, retention, stones.
Gynae: menstruation, pregnancy, endometriosis, salpingitis, endometritis, ovarian cyst torsion.
Gastrointestinal history: causes of generalised abdominal pain
Gastroenteritis.
IBS.
Peritonitis.
Constipation.
Gastrointestinal history: causes of central abdominal pain
Mesenteric ischaemia.
AAA.
Pancreatitis.
Gastrointestinal history: causes of abdominal distension
Fat. Fluid. Flatus. Foetus. Faeces.
Gastrointestinal history: faecal incontinence, overview
This is common in the elderly.
Depends on many factors: mental function, stool (volume and consistency), anatomy (sphincter function, rectal distensibility, anorectal sensation and reflexes).
Defects in any area can cause loss of faecal continence.
Gastrointestinal history: faecal incontinence, causes
Often multifactorial.
Is it passive facial soiling or urgency-related stool loss?
Sphincter dysfunction: vaginal delivery is the commonest cause due to sphincter tears or pudendal nerve damage; surgical trauma, e.g. following procedures for fistulas, haemorrhoids, fissures.
Impaired sensation: diabetes, MS, dementia, any spinal cord lesions- consider cord compression if acute.
Faecal impaction: overflow diarrhoea, extremely common especially in elderly.
Idiopathic.
Gastrointestinal history: faecal incontinence, assessment
PR: overflow incontinence? poor tone?
Assess neurological function of legs, particularly checking sensation.
Refer to specialist, esp. if rectal prolapse, anal sphincter injury, lumbar disc disease, or alarm symptoms for colon Ca coexist.
Consider anorectal manometry, pelvic ultrasound or MRI, and pudendal nerve testing may be needed.
Gastrointestinal history: flatulence
Normally, 400-1300mL of gas is expelled PR in 8-20 discrete or indiscrete episodes per day.
If this, with any eructation (burps) or distension, seems excessive to the patient, they may complain of flatulence.
Eructation occurs in hiatus hernia- but most patients with ‘flatulence’ have no GI disease.
Air swallowing (aerophagy) is the main cause of flatus, with N2 the chief gas.
If flatus is mostly methane, H2 and CO2, then fermentation by bowel bacteria is the cause, and reducing carbohydrate intake e.g. less lactose and wheat may help.
Gastrointestinal history: tenesmus
This is a sensation in the rectum of incomplete emptying after defaecation.
It’s common in IBS, but can be caused by tumours.
Gastrointestinal history: regurgitation
Gastric and oesophageal contents are regurgitated effortlessly into the mouth- without contraction of abdominal muscles and diaphragm (so distinguishing it from true vomiting).
It may be worse on lying flat, and can cause cough and nocturnal asthma.
Regurgitation is rarely preceded by nausea, and when due to gastrooesophageal reflux, it is often associated with heartburn.
An oesophageal pouch may cause regurgitation.
Very high GI obstructions, e.g. gastric volvulus, cause non-productive retching rather than true regurgitation.
Gastrointestinal history: steatorrhoea
These are pale stools that are difficult to flush, and are caused by malabsorption of fat in the small intestine and hence greater fat content in the stool.
Causes: ileal disease, e.g. Crohn’s or ill resection; pancreatic disease; obstructive jaundice (due to reduced excretion of bile salts from the gallbladder).
Gastrointestinal history: dyspepsia
Dyspepsia is one or more of post-prandial fullness, early satiety (unable to finish meal), and/or epigastric or retrosternal pain or burning.
‘Indigestion’ reported by the patient can refer to dyspepsia, bloating, nausea, and vomiting.
Try to find out exactly what the patient means and when these symptoms occur in relation to meals, e.g. the classic symptoms of peptic ulcers occur 2-5 hours after a meal and on an empty stomach.
Look for alarm symptoms, these have high negative predictive value.
If all patients with dyspepsia undergo endoscopy, <33% have clinically significant findings.
Myocardial infarction may present as ‘indigestion’.
Gastrointestinal history: halitosis
Fetor oris, oral malodour, results from gingivitis (rarely severe enough to cause Vincent’s angina), metabolic activity of bacteria in plaque, or sulfide-yielding food putrefaction, e.g. in gingival pockets and tonsillar crypts.
Patients can often be anxious and convinced of halitosis when it is not present, and vice versa.
Contributory factors: smoking, drugs (disulfuram, isosorbide), lung disease, hangovers.
Try to eliminate anaerobes: good dental hygiene, dental floss, tongue scraping, 0.2% aqueous chlorhexidine gluconate.
Abdominal examination: introductions
Begin by introducing yourself, obtaining consent to examine, and positioning the patient appropriately: lie the patient as flat as possible, ideally exposing from ‘nipples to knees’.
In practice, keep the growing covered and examine separately for hernias, etc.
Abdominal examination: general inspection
Assess general state (ill/well/cachectic).
Clues (vomit bowl, stoma bags, catheter, urine colour).
Colour (pale, jaundiced, uraemic).
BMI?
Scars on the abdomen? Stomas?
Ask the patient to lift their head off the bed or cough, looking for bulges, distension or pain.
Abdominal examination: hands
Inspect: clubbing, koilonychia (iron, B12 or folate deficiency), leuconychia (hypoalbuminaemia), Muehrcke’s lines (hypoalbuminaemia), palmar erythema (chronic liver disease, pregnancy), Dupuytren’s contracture (alcoholic liver disease), pigmentation of the palmar creases, blue lunulae (Wilson’s disease).
Asterixis (hepatic encephalopathy, uraemia from renal disease).
Abdominal examination: arms
Check pulse and BP.
Look in the distribution of the SVC (arms, upper chest, upper back) for spider naevi.
Check for track marks, bruising, pigmentation, excoriations, arteriovenous fistulae.
Abdominal examination: neck
Examine cervical and supraclavicular lymph nodes- gastric carcinoma?
JVP: raised in fluid overload (renal dysfunction, liver dysfunction), tricuspid regurgitation (may cause pulsatile hepatomegaly).
Scars from tunnelled harm-dialysis lines or other central venous access.
Abdominal examination: face
Skin and eyes: jaundice, conjunctival pallor, Kayser-Fleischer rings (Wilson’s), xanthelasma (PBC, chronic obstruction), sunken eyes (dehydration).
Mouth: angular stomatitis (thiamine, B12 or iron deficiency), pigmentation (Peutz-Jegher’s syndrome), telangiectasia (Osler-Weber-Rendu/HHT), ulcers (IBD), glossitis (iron, B12 or folate deficiency).
Abdominal examination: abdomen, inspection
Scars: previous surgery, transplant, stoma.
Visible masses, hernias, or pulsation of AAA.
Visible veins suggesting portal hypertension.
Gynaecomastia, hair loss, acanthosis nigricans.
Abdominal examination: abdomen, palpation
Squat by the bedside so that the patient’s abdomen is at your eye level.
Ask if there is any pain and examine this part last.
Watch the patient’s face for signs of discomfort.
Palpate the entire abdomen.
Light palpation: if this elicits pain, check for rebound tenderness, any involuntary tension in muscles (guarding)?
Deep palpation: to detect masses.
Liver: using the radial border of the index finger aligned with the costal margin start palpation from the RIF, press down and ask the patient to take a deep breath, continue upwards towards the costal margin until you feel the liver edge.
Spleen: start palpation in RIF and work towards left costal margin asking the patient to take a deep breathing and feeling for edge of the spleen.
Kidneys: for each kidney, place a hand behind the patent’s loin, press down on the abdomen with the other hand and ‘ballot’ the kidney up with your lower hand against your upper hand- unless slim or pathology present, may not be palpable.
Aorta: palpate midline above umbilicus, is it expansile?
Abdominal examination: percussion
Percuss all regions of the abdomen.
Liver: percuss to map upper and lower border.
Spleen: percuss from border of spleen as palpated, around to mid-axillary line.
Bladder: if enlarged, suprapubic region will be dull.
Ascites: shifting dullness- percuss centrally to laterally until dull, keep your finger at the dull spot and ask patient to lean onto opposite side, if the dullness was fluid, this will now have moved by gravity and the previously dull area will be resonant.
Abdominal examination: auscultation
Bowel sounds: listen in RIF, absence implies ileus, enhanced and tinkling in bowel obstruction.
Bruits: listen over aorta and renal arteries (either side of midline above umbilicus).
Abdominal examination: to complete the examination
Palpate for ankle oedema. Examine hernial orifices. Examine external genitalia. Perform a per rectal examination. Check the observation chart and dipstick urine.
Abdominal examination: examination of the rectum and anus
CHAPERONE.
Explain what you are about to do, ensure adequate privacy and a drape.
Have the patient lie on their left side with knees brought up towards the chest.
Use gloves and lubricant.
Part the buttocks and inspect the anus:
- a gaping anus suggests a neuropathy or megarectum.
- symmetry (a tender unilateral bulge suggests abscess.
- prolapsed piles.
- subanodermal clot may peep out.
- prolapsed rectum (descent of >3cm when asked to strain, as if to pass a motion).
- anodermatitis (from frequent soiling).
- anocutaneous reflex tests sensory and motor innervation- on lightly stroking the anal skin, does the external sphincter briefly contract?
Press your index finger against the side of the anus.
Ask the patient to breathe deeply and insert your finger slowly.
Feel for masses (haemorrhoids are not palpable) or impacted stool.
Twist your arm so that the pad of your finger is feeling anteriorly.
Feel for the cervix or prostate.
Note consistency, size, and symmetry of the prostate.
If there is faecal incontinence or concern about the spinal cord, ask the patient to squeeze your finger and note the tone. This is best done with your finger pad facing posteriorly.
Note stool or blood on the glove and test for occult blood.
Wipe the anus. Consider proctoscopy or sigmoidoscopy.
Abdominal examination: causes of hepatomegaly
Malignancy: metastatic or primary (usually craggy, irregular edge).
Hepatic congestion: right heart failure- may be pulsatile in tricuspid incompetence, hepatic vein thrombosis (Budd-Chiari syndrome).
Anatomical: Riedel’s lobe (normal variant).
Infection: infectious mononucleosis (glandular fever), hepatitis viruses, malaria, schistosomiasis, amoebic abscess, hydatid cyst.
Haematological: leukaemia, lymphoma, myeloproliferative disorders e.g. myelofibrosis, sickle cell disease, haemolytic anaemias.
Others: fatty liver, porphyria, amyloidosis, glycogen storage disorders.
Abdominal examination: causes of massive splenomegaly
Chronic myeloid leukaemia.
Myelofibrosis.
Malaria (or leishmaniasis).
