GI S&S: Abdo Examina+on
Stoma++s = inflamma(on of mouth from any cause e.g. ill-fi8ng dentures. Angular stoma((s = inflamma(on Inspec+on: E.g. abdominal distension; 5Fs = flatus, fat, fetus, fluid,
of corners of mouth. myxedema, jaundice? Scars. Full blown peritoni(s (due to duodenu
‘Burning mouth syndrome’: burning sensa(on with clinically normal oral mucosa; more common in middle- small shallow breaths may hurt. Uraemia may be smelt. Umbilicus:
aged and elderly-females; probably psychogenic in origin. medusa and spider neva; Incisions Abdomen: Distension: pregnanc
Hallitosis= common; poor oral hygiene/ anxiety/ rare causes e.g. oesophageal stricture/ pulmonary sepsis. Palpa+on: palpable masses and tenderness. Start diagonally oppos
Indiges+on: common; 80% popula(on suffer this at some (me. doing exam– see when in pain etc
Dyspepsia: term for many upper abdo symptoms e.g. nausea, heartburn, acidity, pain or discomfort, wind, - Superficial palpa(on- May feel mass – need to describe: In abd
fullness, belching. Alarm symptoms = Features of dyspepsia sugges(ve of serious disease e.g. cancer = resistance; Below abdo wall – wont be felt when try and sit up
dysphagia, weight loss, vomi(ng, anorexia, haematemesis, meleana: inves(gate pt with these up against resistance. Mass in RIF: always an appendix mass
Nausea: feeling WANT to vomit (oMen assoc with hypersaliva(on, pallor, swea(ng); oMen precedes vomi(ng - Deeper palpa(on: How much pain
Retching: strong invol effort to vomit, with abdo muscle contrac(on but w/o expulsion of gastric contents. When palpa(ng, bed needs to be at same level at which palpa(ng.
Vomi+ng: expulsion of gastric contents through mouth. Many GI and non-GI causes. Vomi(ng is controlled by let go – more pain (posi(ve in appendici(s)
complex reflex inv central neural control centres, located in later re(cular forma(on of medulla, which are Palpate for liver – normally not felt; palpate for spleen – normally n
s(mulated in chemoreceptor trigger zones in floor of 4th V and also by vagal afferents from gut. Central zones Glandular fever, HIV, CMV,
directly s(mulated by toxins, drugs, mo(on sickness, metabolic disturbances. Raised ICP has direct effect on Effects: Any ascites? Dull on percussion – tympani(c; ShiMing dulln
vomi(ng centre à vomi(ng. Local GI causes: luminal toxins, inflamma(on, mechanical obstruc(on. Kidneys: Bilateral examina(on
Causes of Vomi+ng: Any GI disease; DKA; Psychogenic; Pregnancy; Infxns (viruses, influenza, norovirus, Percussion: areas of dullness caused by liver and spleen, ascites (fl
bacterial – pertussis, UTI), Alcohol excess, CNS disease, raised ICP, ves(bular disturbance e.g. mo(on sickness, dullness if 1-2L fluid present) or over masses. Full bladder dull.
migraine; Drugs: Abx, chemo, digoxin, immuno-suppressives (E.g. aza), levodopa, opiates, Metabolic: uraemia Ausculta+on: Bowel sounds: Increased high-pitched (nkling bowel
and hyperclacaemia; Reflex: MI or biliar colic to fluid movement within dilated bowel lumen); Absent bowel sou
Faeculent vomit: suggests lower intes(nal obs/ presence of gastrocolic fistula absent bowel sounds suggest strangula(on, ischaemia or ileus; if in
Haematemesis: vomi(ng fresh/ altered blood (“coffee ground”) essen(al to examine hernial orifices. Groin: femoral artery narrowi
Early AM N&V: Seen in pregnancy, alcohol dependence, some metabolic disease have pelvic mass/abscess; in acute appendici(s always do rectal ex
Persistent nausea: oMen stress related, not due to GI disease Examina(on of the rectum and sigmoid colon: DRE in all pt with ch
Flatulence = excessive wind; belching, abdo distension, gurgling, passage of flatus PR. Some swallowed air and prior to protoscopy/ sigmoidoscopy. Protoscopy: All with brigh
(aerophagia) is not absorbed in intes(ne, and passes rectally. Colonic bacterial breakdown of non-absorbed anorectal pathology e.g. haemorrhoids. Sigmoidoscopy: rou(ne ho
carbohydrate also produces gas. Rectal flatus consists of: N2, CO2, H2, methane. Normal to pass rectal flatus in pt with lower abdo symptoms e.g. changed bowel habit or recta
up to 20x daily. Causes of inc gas produc(on and intake: high-fibre diet and carbonated drinks. maximum of 20-25cm distal colon
Diarrhoea and Cons+pa+on: Common complaints; not usually serious. Cons(pa(on: difficult passage of hard Flexible sigmoidoscopy: 60cm can reach up to splenic flexure; used
stool (irrespec(ve of frequency); cons(pa(on with hard stools is rarely due to organic colonic disease. frequency/looseness, or rectal bleeding to diagnose coli(s or polyp
Abdo Pain: Pain s(mulated mainly by stretching of smooth muscle/organ capsules. Severe acute abdo pain Stool Examina+on:
may be due to large number of GI condi(ons, normallypresen(ng as an emergency. Apparent ‘acute abdo’ RIF pain – differen(al diagnosis: Appendici(s. In women: gynae pro
can occasionally be due to referred pain from chest e.g. pneumonia or due to metabolic causes e.g. DKA or ovaries; cys(c bleeding). In men: Meckel’s diver(culi(s, Crohn’s. U
porphyria. Check: site, character, intensity, dura(on, frequency of pain. Aggrava(ng and relieving factors, and tenderness localized to RIF; RIF pain: appendici(s
associated symptoms (including non-GI symptoms) Presen(ng with shock: Haematemesis; Ectopic pregnancy in wome
Upper Abdominal Pain: Epigastric pain = very common; oMen related to food intake. Func(onal dyspepsia = Good ligh(ng; Adequate exposure: nipple to knees; Strangulated fe
commonest cause but can also be caused by pep(c ulcer disease. GORD: retrosternal burning pain hernia; Include inguinal and femoral regions; Abdo examina(on inc
(heartburn) Specialised tests: Confirm findings (e.g. enlarged liver/spleen) with
Right hypochondriac pain: may originate from gallbladder or biliary tract. Biliary pain: can be epigastric; Three condi(ons in which must examine pa(ent standing: Hernia;
typically intermiient and severe, lasts a few hours and remits spontaneously to recur weeks/months later obvious when standing; bag of worms)
Hepa(c Conges(on (e.g. hepa((s/ cardiac failure) and some(mes pep(c ulcer disease can present with right General condi(on of pt: look ill? Shocked? Large vol of fluid may be
hypochondriac pain. Chronic, persistant or constant right (or leM) hypochondrial pain in well-looking pt = into peritoneal cavity/lumen of bowel àabsence of guarding (invo
frequent func(onal symptom; NOT due to GB disease. indica(ng peritoni(s)
Lower Abdominal Pain: Pain in leM iliac fossa: may be chronic in origin (e.g. acute diver(culi(s) but chronic Vaginal and Rectal Examina+on: vag exam can be very helpful, esp
pain most commonly associated with func(onal bowel disorders. Lower abdo pain in women: occur in abdomen (e.g. ruptured ectopic pregnancy). Flexible sigmoidoscop
numerous gynae disorders and differen(a(on from GI disease may be difficult. Pain in right iliac fossa may be flexible sigmoidoscopy may be indicated to aid exclusion of infec(v
due to acute appendici(s or ileocaecal disease, but may also commonly be func(onal. Proctalgia fugax causes of acute pain. Specimen of stool should be taken for stool c
(severe pain deep in rectum; comes on suddenly lasts only for a short (me; not due to organic disease) Campylobacter, Salmonella, Shigella and Clostridium difficile toxin)
Abdominal wall pain: Persistent abdo pain with localised tenderness; not relieved by tensing abdo muscles; Other observa(ons: Mouth: tongue furred/ fetor may be present;
probably from abdo wall itself. Causes: nerve entrapment, external hernias and entrapment of internal inflammatory processes. Urine: Examine for blood (suggests UTI or
viscera (commonly omentum) within trauma(c/surgical altera(ons of abdominal wall musculature. (ketoacidosis can present with acute pain), protein and white cells
Anorexia = reduced appe(te; systemic disease; psych disorders. OMen with cancer, usually late symptom. Think of medical causes
Weight loss almost always due to reduced food intake; frequent accompaniment of GI disease. Weight loss in
malabsorp(on disorders primarily due to anorexia; weight loss with normal/increased dietary intake only
occurs with hyperthyroidism and other catabolic state.
Differen+al diagnosis of acute abdomen
Non-specific abdominal pain (30%): Give suppository so can open
appendici(s (30%); Acute cholecys((s (10%) – mainly stones. Smal
Inves+ga+ons and adhesions. Acute pancrea((s - Serum amylase important; PET
Blood count: raised WCC in inflammatory condi(ons gynaeocological condi(ons; Urinary condi(ons; Pep(c Ulcers (H. Py
Serum amylase: high (>5x N) indicate pancrea((s; raised levels below this can occur in any acute Diver(cular disease; Referred pain from pneumonia; Glaucoma can
abdomen and are not diagnos(c of pancrea((s. (may see nothing except increased sensa(on along dermatome the
Serum electrolytes: not par(cularly helpful for dg, but useful for general evalua(on of pt. obstruc(on- seen on x-ray; Leaking aneurysm: acute emergency; p
Pregnancy test: urine dips(ck used for women of child-bearing age Appendix abscess – late stage of appendici(s; Usually need to be d
X-rays: CXR useful to detect air under diaphragm (indicates perfora(on); dilated loops of bowel/fluid levels = appendix abscess. Appendix mass: think of cecum tumour also
sugges(ve of obstruc(on (erect and supine abdo x-ray req) Psoas abscess: TB; IVDU who inject into groin; Mesenteric glands m
US: useful for dg of acute cholangi(s, cholecys((s and aor(c aneurysm; in expert hands = reliable for dg of Abscess; Absorbable sutures; Drainage consist of corrugated drain
acute appendici(s. Gynae and other pelvic causes of pain can be detected another where appendix remove; today some(mes just given an(b
-CT scan: spiral CT of abdo and pelvis = most accurate inves(ga(on in most acute emergencies. Appendix: aggrega(on of lymphocytes (similar to tonsils and peyer
Laparoscopy: gained inc importance as diagnos(c tool prior to preceding with surgery, especially in men and Tonsils and Peyers patches: first organs to detect infec(on
women >50 years. In addi(on, therapeu(c manoeuvres e.g. appendicectomy can be performed. Effects of splenectomy: sep(caemia and death (50% in children, lo
systemic infec(ons; following splenectomy require life-(me penici
pneumococcus, meningi(s and influenza)
Pain
Onset, site, type and subsequent course of pain: need to be determined ASAP.
Pain can either be constant (usually inflamma(on) or colicky (due to obstructed tube) Acute Appendici+s
Inflammatory nature: constant pain, raised temp, tachycardia, raised WCC. If these are normal, other causes Acute appendici(s = common surgical emergency; affects all age g
(musculoskeletal, aor(c aneurysm) or rare causes (porphyria) should be considered. Inflam condi(ons (e.g. appendix has not been removed. Mostly occurs when lumen of ap
appendici(s) produce more gradual onset of pain. Peritoni(s: pain con(nuous and worsens with movement faecolith; in some cases however only generalised acute inflamma
Colicky pain can be due to: obstruc(on of gut, biliary system, urogenital system or uterus: probably req ini(al stage, gangrene occurs with perfora(on à localised abscess/ gene
conserva(ve management + analgesics. If colicky pain becomes constant, inflamma(on of organ may have Clinical Features: abdo pain; starts vaguely in centre of abdomen a
supervened (strangulated hernia, ascending cholangi(s or salpingi(s) N&V, anorexia and occasional diarrheoa. O/E: tenderness in RIF wi
Stoma++s = inflamma(on of mouth from any cause e.g. ill-fi8ng dentures. Angular stoma((s = inflamma(on Inspec+on: E.g. abdominal distension; 5Fs = flatus, fat, fetus, fluid,
of corners of mouth. myxedema, jaundice? Scars. Full blown peritoni(s (due to duodenu
‘Burning mouth syndrome’: burning sensa(on with clinically normal oral mucosa; more common in middle- small shallow breaths may hurt. Uraemia may be smelt. Umbilicus:
aged and elderly-females; probably psychogenic in origin. medusa and spider neva; Incisions Abdomen: Distension: pregnanc
Hallitosis= common; poor oral hygiene/ anxiety/ rare causes e.g. oesophageal stricture/ pulmonary sepsis. Palpa+on: palpable masses and tenderness. Start diagonally oppos
Indiges+on: common; 80% popula(on suffer this at some (me. doing exam– see when in pain etc
Dyspepsia: term for many upper abdo symptoms e.g. nausea, heartburn, acidity, pain or discomfort, wind, - Superficial palpa(on- May feel mass – need to describe: In abd
fullness, belching. Alarm symptoms = Features of dyspepsia sugges(ve of serious disease e.g. cancer = resistance; Below abdo wall – wont be felt when try and sit up
dysphagia, weight loss, vomi(ng, anorexia, haematemesis, meleana: inves(gate pt with these up against resistance. Mass in RIF: always an appendix mass
Nausea: feeling WANT to vomit (oMen assoc with hypersaliva(on, pallor, swea(ng); oMen precedes vomi(ng - Deeper palpa(on: How much pain
Retching: strong invol effort to vomit, with abdo muscle contrac(on but w/o expulsion of gastric contents. When palpa(ng, bed needs to be at same level at which palpa(ng.
Vomi+ng: expulsion of gastric contents through mouth. Many GI and non-GI causes. Vomi(ng is controlled by let go – more pain (posi(ve in appendici(s)
complex reflex inv central neural control centres, located in later re(cular forma(on of medulla, which are Palpate for liver – normally not felt; palpate for spleen – normally n
s(mulated in chemoreceptor trigger zones in floor of 4th V and also by vagal afferents from gut. Central zones Glandular fever, HIV, CMV,
directly s(mulated by toxins, drugs, mo(on sickness, metabolic disturbances. Raised ICP has direct effect on Effects: Any ascites? Dull on percussion – tympani(c; ShiMing dulln
vomi(ng centre à vomi(ng. Local GI causes: luminal toxins, inflamma(on, mechanical obstruc(on. Kidneys: Bilateral examina(on
Causes of Vomi+ng: Any GI disease; DKA; Psychogenic; Pregnancy; Infxns (viruses, influenza, norovirus, Percussion: areas of dullness caused by liver and spleen, ascites (fl
bacterial – pertussis, UTI), Alcohol excess, CNS disease, raised ICP, ves(bular disturbance e.g. mo(on sickness, dullness if 1-2L fluid present) or over masses. Full bladder dull.
migraine; Drugs: Abx, chemo, digoxin, immuno-suppressives (E.g. aza), levodopa, opiates, Metabolic: uraemia Ausculta+on: Bowel sounds: Increased high-pitched (nkling bowel
and hyperclacaemia; Reflex: MI or biliar colic to fluid movement within dilated bowel lumen); Absent bowel sou
Faeculent vomit: suggests lower intes(nal obs/ presence of gastrocolic fistula absent bowel sounds suggest strangula(on, ischaemia or ileus; if in
Haematemesis: vomi(ng fresh/ altered blood (“coffee ground”) essen(al to examine hernial orifices. Groin: femoral artery narrowi
Early AM N&V: Seen in pregnancy, alcohol dependence, some metabolic disease have pelvic mass/abscess; in acute appendici(s always do rectal ex
Persistent nausea: oMen stress related, not due to GI disease Examina(on of the rectum and sigmoid colon: DRE in all pt with ch
Flatulence = excessive wind; belching, abdo distension, gurgling, passage of flatus PR. Some swallowed air and prior to protoscopy/ sigmoidoscopy. Protoscopy: All with brigh
(aerophagia) is not absorbed in intes(ne, and passes rectally. Colonic bacterial breakdown of non-absorbed anorectal pathology e.g. haemorrhoids. Sigmoidoscopy: rou(ne ho
carbohydrate also produces gas. Rectal flatus consists of: N2, CO2, H2, methane. Normal to pass rectal flatus in pt with lower abdo symptoms e.g. changed bowel habit or recta
up to 20x daily. Causes of inc gas produc(on and intake: high-fibre diet and carbonated drinks. maximum of 20-25cm distal colon
Diarrhoea and Cons+pa+on: Common complaints; not usually serious. Cons(pa(on: difficult passage of hard Flexible sigmoidoscopy: 60cm can reach up to splenic flexure; used
stool (irrespec(ve of frequency); cons(pa(on with hard stools is rarely due to organic colonic disease. frequency/looseness, or rectal bleeding to diagnose coli(s or polyp
Abdo Pain: Pain s(mulated mainly by stretching of smooth muscle/organ capsules. Severe acute abdo pain Stool Examina+on:
may be due to large number of GI condi(ons, normallypresen(ng as an emergency. Apparent ‘acute abdo’ RIF pain – differen(al diagnosis: Appendici(s. In women: gynae pro
can occasionally be due to referred pain from chest e.g. pneumonia or due to metabolic causes e.g. DKA or ovaries; cys(c bleeding). In men: Meckel’s diver(culi(s, Crohn’s. U
porphyria. Check: site, character, intensity, dura(on, frequency of pain. Aggrava(ng and relieving factors, and tenderness localized to RIF; RIF pain: appendici(s
associated symptoms (including non-GI symptoms) Presen(ng with shock: Haematemesis; Ectopic pregnancy in wome
Upper Abdominal Pain: Epigastric pain = very common; oMen related to food intake. Func(onal dyspepsia = Good ligh(ng; Adequate exposure: nipple to knees; Strangulated fe
commonest cause but can also be caused by pep(c ulcer disease. GORD: retrosternal burning pain hernia; Include inguinal and femoral regions; Abdo examina(on inc
(heartburn) Specialised tests: Confirm findings (e.g. enlarged liver/spleen) with
Right hypochondriac pain: may originate from gallbladder or biliary tract. Biliary pain: can be epigastric; Three condi(ons in which must examine pa(ent standing: Hernia;
typically intermiient and severe, lasts a few hours and remits spontaneously to recur weeks/months later obvious when standing; bag of worms)
Hepa(c Conges(on (e.g. hepa((s/ cardiac failure) and some(mes pep(c ulcer disease can present with right General condi(on of pt: look ill? Shocked? Large vol of fluid may be
hypochondriac pain. Chronic, persistant or constant right (or leM) hypochondrial pain in well-looking pt = into peritoneal cavity/lumen of bowel àabsence of guarding (invo
frequent func(onal symptom; NOT due to GB disease. indica(ng peritoni(s)
Lower Abdominal Pain: Pain in leM iliac fossa: may be chronic in origin (e.g. acute diver(culi(s) but chronic Vaginal and Rectal Examina+on: vag exam can be very helpful, esp
pain most commonly associated with func(onal bowel disorders. Lower abdo pain in women: occur in abdomen (e.g. ruptured ectopic pregnancy). Flexible sigmoidoscop
numerous gynae disorders and differen(a(on from GI disease may be difficult. Pain in right iliac fossa may be flexible sigmoidoscopy may be indicated to aid exclusion of infec(v
due to acute appendici(s or ileocaecal disease, but may also commonly be func(onal. Proctalgia fugax causes of acute pain. Specimen of stool should be taken for stool c
(severe pain deep in rectum; comes on suddenly lasts only for a short (me; not due to organic disease) Campylobacter, Salmonella, Shigella and Clostridium difficile toxin)
Abdominal wall pain: Persistent abdo pain with localised tenderness; not relieved by tensing abdo muscles; Other observa(ons: Mouth: tongue furred/ fetor may be present;
probably from abdo wall itself. Causes: nerve entrapment, external hernias and entrapment of internal inflammatory processes. Urine: Examine for blood (suggests UTI or
viscera (commonly omentum) within trauma(c/surgical altera(ons of abdominal wall musculature. (ketoacidosis can present with acute pain), protein and white cells
Anorexia = reduced appe(te; systemic disease; psych disorders. OMen with cancer, usually late symptom. Think of medical causes
Weight loss almost always due to reduced food intake; frequent accompaniment of GI disease. Weight loss in
malabsorp(on disorders primarily due to anorexia; weight loss with normal/increased dietary intake only
occurs with hyperthyroidism and other catabolic state.
Differen+al diagnosis of acute abdomen
Non-specific abdominal pain (30%): Give suppository so can open
appendici(s (30%); Acute cholecys((s (10%) – mainly stones. Smal
Inves+ga+ons and adhesions. Acute pancrea((s - Serum amylase important; PET
Blood count: raised WCC in inflammatory condi(ons gynaeocological condi(ons; Urinary condi(ons; Pep(c Ulcers (H. Py
Serum amylase: high (>5x N) indicate pancrea((s; raised levels below this can occur in any acute Diver(cular disease; Referred pain from pneumonia; Glaucoma can
abdomen and are not diagnos(c of pancrea((s. (may see nothing except increased sensa(on along dermatome the
Serum electrolytes: not par(cularly helpful for dg, but useful for general evalua(on of pt. obstruc(on- seen on x-ray; Leaking aneurysm: acute emergency; p
Pregnancy test: urine dips(ck used for women of child-bearing age Appendix abscess – late stage of appendici(s; Usually need to be d
X-rays: CXR useful to detect air under diaphragm (indicates perfora(on); dilated loops of bowel/fluid levels = appendix abscess. Appendix mass: think of cecum tumour also
sugges(ve of obstruc(on (erect and supine abdo x-ray req) Psoas abscess: TB; IVDU who inject into groin; Mesenteric glands m
US: useful for dg of acute cholangi(s, cholecys((s and aor(c aneurysm; in expert hands = reliable for dg of Abscess; Absorbable sutures; Drainage consist of corrugated drain
acute appendici(s. Gynae and other pelvic causes of pain can be detected another where appendix remove; today some(mes just given an(b
-CT scan: spiral CT of abdo and pelvis = most accurate inves(ga(on in most acute emergencies. Appendix: aggrega(on of lymphocytes (similar to tonsils and peyer
Laparoscopy: gained inc importance as diagnos(c tool prior to preceding with surgery, especially in men and Tonsils and Peyers patches: first organs to detect infec(on
women >50 years. In addi(on, therapeu(c manoeuvres e.g. appendicectomy can be performed. Effects of splenectomy: sep(caemia and death (50% in children, lo
systemic infec(ons; following splenectomy require life-(me penici
pneumococcus, meningi(s and influenza)
Pain
Onset, site, type and subsequent course of pain: need to be determined ASAP.
Pain can either be constant (usually inflamma(on) or colicky (due to obstructed tube) Acute Appendici+s
Inflammatory nature: constant pain, raised temp, tachycardia, raised WCC. If these are normal, other causes Acute appendici(s = common surgical emergency; affects all age g
(musculoskeletal, aor(c aneurysm) or rare causes (porphyria) should be considered. Inflam condi(ons (e.g. appendix has not been removed. Mostly occurs when lumen of ap
appendici(s) produce more gradual onset of pain. Peritoni(s: pain con(nuous and worsens with movement faecolith; in some cases however only generalised acute inflamma
Colicky pain can be due to: obstruc(on of gut, biliary system, urogenital system or uterus: probably req ini(al stage, gangrene occurs with perfora(on à localised abscess/ gene
conserva(ve management + analgesics. If colicky pain becomes constant, inflamma(on of organ may have Clinical Features: abdo pain; starts vaguely in centre of abdomen a
supervened (strangulated hernia, ascending cholangi(s or salpingi(s) N&V, anorexia and occasional diarrheoa. O/E: tenderness in RIF wi
