Symptomatology of Gastrointestinal System III Term Dept of Medicine ACMS
Symptomatologyof
Gastrointestinal System
III Term
Dept of Medicine ACMS
Learning Objectives
• Learn definitions and meanings of common terms associated with gastrointestinal symptoms
• Learn to localize disease from symptoms
Gastrointestinal Symptoms
• Most common presenting complaints in OPD setting
• Great overlap of symptoms in GI Disorders
• Overlap with other systems and sites
• Severity does not correlate well with seriousness of disease
Divisions
• Upper GI-Above DJ Flexure
Divisions
• Upper GI
• Middle GI-
Uptil Ileoceacal Junction
Divisions
• Upper GI
• Middle GI
• Lower GI- Upto anal verge
Divisions
• Upper GI
• Middle GI
• Lower GI
• Liver and Biliary Tract
Divisions
• Upper GI
• Middle GI
• Lower GI
• Liver and Biliary Tract
• Pancreas
Divisions
• Upper GI
• Middle GI
• Lower GI
• Liver and Biliary Tract
• Pancreas
Considerable overlap of
symptoms
Upper GI Symptoms
Upper GI Symptoms
• Dysphagia and Odynophagia-
Upper GI Symptoms
• Dysphagia and Odynophagia- Difficulty and pain in swallowing
Upper GI Symptoms
• Dysphagia and Odynophagia- Difficulty and pain in swallowing
• Esophagitis
• Achalasia – motility disturbance
• Stricture
• Carcinoma
Upper GI Symptoms
• Heartburn, Regurgitation &Reflux (eructation)-
Upper GI Symptoms
• Heartburn, Regurgitation &Reflux (eructation)-
• GERD-Reflux Esophagitis
• Gastritis
• Peptic Ulcer Disease
Upper GI Symptoms
• Dyspepsia –
Upper GI Symptoms
• Dyspepsia - Combination of Indigestion, pain, distention, acidity, nausea (and Hunger Pains)
Upper GI Symptoms
• Dyspepsia - Combination of Indigestion, pain, distention, acidity, nausea (and Hunger Pains)
• Gastroduodenitis
• Chronic Pancreatitis
• Chronic Cholecystitis
• Hepatitis
• Carcinoma Stomach and Pancreas
Upper GI Symptoms
• Flatulence
Upper GI Symptoms
• Flatulence (Burping, Belching, Flatus)
Upper GI Symptoms
• Flatulence (Burping, Belching, Flatus)
• Chronic Pancreatitis
• Gastroduodenitis
• Anxiety
• Food Intolerance
Upper GI Symptoms
• Anorexia-
Upper GI Symptoms
• Anorexia- Reduced appetite
Upper GI Symptoms
• Anorexia- Reduced appetite
• Hepatitis
• Gastroduodenitis
• Gastroenteritis
• Carcinoma
Upper GI Symptoms
• Nausea, Retching &Vomiting
Upper GI Symptoms
• Nausea, Retching &Vomiting
• Gastroduodenitis, Gastroenteritis
• Hepatitis, Pancreatitis, Cholecystitis
• Pyloric Obstruction, Carcinoma
Upper GI Symptoms
• Hematemesis-
Upper GI Symptoms
• Hematemesis- Blood in Vomit
Upper GI Symptoms
• Hematemesis- Blood in Vomit
• Esophageal Varices
• Acute Gastritis
• Peptic Ulcer
• Gastric cancer
Upper GI Symptoms
• Hematemesis- Blood in Vomit
• Esophageal Varices
• Acute Gastritis
• Peptic Ulcer
• Gastric cancer
• Melaena-
Upper GI Symptoms
• Hematemesis- Blood in Vomit
• Esophageal Varices
• Acute Gastritis
• Peptic Ulcer
• Gastric cancer
• Melaena- Digested blood passed in stool
Upper GI Symptoms
• Dysphagia and Odynophagia
• Heartburn and Reflux (eructation)
• Dyspepsia and Hunger Pains
• Flatulence (Burping, Belching, Flatus)
• Anorexia
• Nausea, Retching &Vomiting
• Hematemesis and Maelena
Lower GI Diseases
Lower GI Diseases• Enteritis/ Ileitis
• Meckel's Diverticulitis
• Diverticulitis
• Crohn’s Disease
• Colitis (idiopathic, infectious)
• Colonic polyps
• Carcinoma
• Hemorrhoids
• Fissure
• Irritable bowel syndrome
• Ischemic colitis
• Radiation colitis
• Omental torsion
• Mesenteric lymphadenitis
Lower GI Symptoms
Lower GI Symptoms
• Constipation-
Lower GI Symptoms
• Constipation- Less than 3 stools/ week. Hard, pellet like and difficult to pass
Lower GI Symptoms
• Diarrhea, Dysentery & Spurious Diarrhea
Lower GI Symptoms
• Diarrhea, Dysentery & Spurious Diarrhea
• > 200 -300 gm /day
• >3 times / day- liquid consistency
• Mucous and Blood
Lower GI Symptoms
• Tenismus-
Lower GI Symptoms
• Tenismus- Sense of incomplete evacuation
Lower GI Symptoms
• Alteration of Bowel Pattern
Lower GI Symptoms
• Proctalgia:
Lower GI Symptoms
• Proctalgia: Painful Defecation
Lower GI Symptoms
• Rectal Bleeding
Lower GI Symptoms
• Hematochezia
General Symptoms• Pain
• Distention & Swelling
• Weight Loss
• Fever
• Malnutrition and Hypovitaminosis
Abdominal Pain: Pathophysiology
• Three classes of abdominal pain
Abdominal Pain: Pathophysiology
• Three classes of abdominal pain
1) Visceral
Abdominal Pain: Pathophysiology
• Three classes of abdominal pain
1) Visceral
2) Somatic
Abdominal Pain: Pathophysiology
• Three classes of abdominal pain
1) Visceral
2) Somatic
3) Referred
Abdominal Pain: Pathophysiology
• Three classes of abdominal pain
1) Visceral
2) Somatic
3) Referred
Visceral Pain
Originates in-
• the walls of hollow organs
• the capsules of solid organs
• the visceral peritoneum
Visceral Pain
Originates in-
• the walls of hollow organs
• the capsules of solid organs
• the visceral peritoneum
Three separate mechanisms can produce this pain:
Visceral Pain
Originates in-
• the walls of hollow organs
• the capsules of solid organs
• the visceral peritoneum
Three separate mechanisms can produce this pain:
1) Inflammation
2) Distention (being stretched out or inflated)
3) Ischemia (inadequate blood flow)
Visceral Pain
• All viscera transmit a pain signal from visceral afferent neural fibers back to the spinal column
Visceral Pain
• All viscera transmit a pain signal from visceral afferent neural fibers back to the spinal column
• Pain is usually not localized to any one specific area
• Described as very vague or poorly localized, dull or crampy
Visceral Pain
• All viscera transmit a pain signal from visceral afferent neural fibers back to the spinal column
• Pain is usually not localized to any one specific area
• Described as very vague or poorly localized, dull or crampy
• Body responds through parasympathetic stimulation causing Nausea/Vomiting, Diaphoresis and Bradycardia
Somatic Pain
Somatic Pain
• Sharp pain that travels along definite neural routes (dermatomes) to the spinal cord
Somatic Pain
• Sharp pain that travels along definite neural routes (dermatomes) to the spinal cord
Usually associated with-
Somatic Pain• Sharp pain that travels along definite neural routes
(dermatomes) to the spinal cord
Usually associated with-
Perforations or ruptures of hollow organs- Peritonitis
– bacterial (ruptured appendix or gall bladder)
– chemical (perforated ulcer or inflamed pancreas)
Abdominal wall lesions-
– Contusion
– Hematoma
– Tumor
Referred Pain
Referred Pain• Originates in a region other than where it is felt
Referred Pain• Originates in a region other than where it is felt.
• Many neural pathways from various organs pass through regions where the organ was formed during embryonic development.
Referred Pain• Originates in a region other than where it is felt.
• Many neural pathways from various organs pass through regions where the organ was formed during embryonic development.
• Examples:
1. Inflammation of diaphragm causes referred pain in neck or shoulder
Referred Pain• Originates in a region other than where it is felt.
• Many neural pathways from various organs pass through regions where the organ was formed during embryonic development.
• Examples:
1. Inflammation of diaphragm causes referred pain in neck or shoulder
2. Dissecting abdominal aortic aneurysm produces referred pain between shoulder blades
History of Pain AbdomenOPQRST-ASPN
History of Pain AbdomenOPQRST-ASPN
1. Onset: when did the pain start, was it sudden or gradual?
History of Pain AbdomenOPQRST-ASPN
1. Onset: when did the pain start, was it sudden or gradual?
2. Provocation/Palliation: makes the pain worse or better?
History of Pain AbdomenOPQRST-ASPN
1. Onset: when did the pain start, was it sudden or gradual?
2. Provocation/Palliation: makes the pain worse or better?
3. Quality: dull, sharp, constant?
History of Pain AbdomenOPQRST-ASPN
1. Onset: when did the pain start, was it sudden or gradual?
2. Provocation/Palliation: makes the pain worse or better?
3. Quality: dull, sharp, constant?
4. Region/radiation: pain travel?
History of Pain AbdomenOPQRST-ASPN
1. Onset: when did the pain start, was it sudden or gradual?
2. Provocation/Palliation: makes the pain worse or better?
3. Quality: dull, sharp, constant?
4. Region/radiation: pain travel?
5. Severity: scale 1-10
History of Pain AbdomenOPQRST-ASPN
1. Onset: when did the pain start, was it sudden or gradual?
2. Provocation/Palliation: makes the pain worse or better?
3. Quality: dull, sharp, constant?
4. Region/radiation: pain travel?
5. Severity: scale 1-10
6. Time: when and how long?
History of Pain AbdomenOPQRST-ASPN
1. Onset: when did the pain start, was it sudden or gradual?
2. Provocation/Palliation: makes the pain worse or better?
3. Quality: dull, sharp, constant?
4. Region/radiation: pain travel?
5. Severity: scale 1-10
6. Time: when and how long?
7. Associated Symptoms
History of Pain AbdomenOPQRST-ASPN
1. Onset: when did the pain start, was it sudden or gradual?
2. Provocation/Palliation: makes the pain worse or better?
3. Quality: dull, sharp, constant?
4. Region/radiation: pain travel?
5. Severity: scale 1-10
6. Time: when and how long?
7. Associated Symptoms
8. Pertinent Negatives
Abdominal DistentionFluid Gaseous
Abdominal DistentionFluid
• Ascites
• Peritonitis
• Perforations
• Abscess
• Hemorrhage
Gaseous
Abdominal DistentionFluid
• Ascites
• Peritonitis
• Perforations
• Abscess
• Hemorrhage
Gaseous
• Ileitis and Colitis
• Intestinal Obstruction
• Adhesions
• Intusseption
• Volvulus
• Messenteric ischemia
Ascites and Malnutrition
Malnutrition
• Macronutrients & Micronutrients
Malnutrition
• Macronutrients & Micronutrients
• Malabsorbtion & maldigestion
Hypovitaminosis
Liver & Biliary Tract
• Acute Hepatitis
• Chronic Hepatitis
• Cirrhosis
• Cholecystitis
• Cholelithiasis
• Hepatocellular Carcinoma
• Gall Bladder Cancer
Symptoms of Liver & Biliary Tract
• Jaundice
Icterus
High Colored Urine
Liver & Biliary Tract
• Jaundice
• Itching
Pruritus
Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia, nausea, vomiting – as for Upper GI
Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia nausea vomiting
• Pain – Visceral, Somatic, Referred
Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia nausea vomiting
• Pain
• Fever- Infections and Malignancy
Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia nausea vomiting
• Pain
• Fever
• Bleeding manifestations- Coagulation Factors, Hypersplenism, DIC
Subconjunctival Hemorrhage
Ecchymoses
Petechiae
Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia nausea vomiting
• Pain
• Fever
• Bleeding manifestations
• Fluid Distention-Ascites, Peritonitis, Hemoperitoneum
Fluid Distention
Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia, nausea, vomiting
• Pain
• Fever
• Bleeding manifestations
• Fluid Distention
• Altered Sensorium- Encephalopathy
Altered Sensorium
Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia, nausea, vomiting
• Pain
• Fever
• Bleeding manifestations
• Fluid Distention
• Altered Sensorium
• Lump Abdomen
Lump Abdomen- Spleen
Gall Bladder Lump
Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia nausea vomiting
• Pain
• Fever
• Bleeding manifestations
• Fluid Distention
• Altered sensorium
• Lump Abdomen
• Breast Enlargement
Gynaecomastia- Breast Enlargement
Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia nausea vomiting
• Pain
• Fever
• Bleeding manifestations
• Fluid Distention
• Altered sensorium
• Lump Abdomen
• Breast Enlargement
• Parotid Enlargement
Parotid Enlargement
Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia nausea vomiting
• Pain
• Fever
• Bleeding manifestations
• Fluid Distention
• Altered sensorium
• Lump Abdomen
• Breast Enlargement
• Parotid Enlargement
• Spider Angiomata
Spider Angiomata
Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia, Nausea, Vomiting
• Pain
• Fever
• Bleeding manifestations
• Fluid Distention
• Altered Sensorium
• Lump Abdomen
• Breast Enlargement
• Parotid Enlargement
• Spider Angiomata
• Dupuytren’s Contracture
Dupuytren’s Contracture
Symptoms of Acute Pancreatic Disorders
• Fever
• Pain- excruciating, continuous
• Vomiting- no relief in pain
• Distention- gaseous and fluid
• Jaundice- variable
Symptoms of Chronic Pancreatic Disorders
• Anorexia
• Dyspepsia
• Diarrhea
• Steatorrhea
• Malnutrition
• Diabetes
Case 1: 22 year old foreign tourist, had street food in Sarojini Nagar last night
• Fever with chills
• Colicky pain abdomen
• Nausea &vomiting 4 times
• Profuse watery diarrhea 8 times
All for 8 hours
Case 2: 40 Year old housewife
Having Dyspepsia off and on for 1 year
• Fever
• Pain Upper Abdomen
• Vomiting and retching
• Yellow discoloration of urine
All for 2 days
• Pale stools this morning
Case 3: 50 Year old Alcoholic X 30 Years
• Recurrent pain abdomen and dyspepsia after alcohol X 2 years
• Jaundice 1 year ago
• Lump in abdomen since 1 year
• Fresh Blood in vomiting 6 months ago
• Vomiting & painful abdominal distention X 3 D
• Fever X 2 days
25 year old lady on antidepressants X 1 month
• Hard stools X 3 weeks
• Painful defecation X 1 week
• Bleeding after passage of stool X 1 day
40 year old businessman
• Constipation X 1 month
• Intermittent large watery stool after initial passage of hard motion every 3 to 4 days
• Weight loss of 3 Kgs in last month
• Blood in stool yesterday
55 year old obese, smoker and alcoholic
Taking Antacids for Heartburn and Dyspepsia for several years
• Difficulty in swallowing solids X 1 month
• Vomiting of undigested food X 3 weeks
• Difficulty in swallowing liquids X 1 week
• Weight loss of 8 Kgs in 2 months
40 year old teacher
• Pain & stiffness in small &large joints X 2 M. Recently diagnosed as Rheumatoid Arthritis Prescribed multiple medications
• Dyspepsia and pain abdomen X 1 week
• Tarry stools X 2 days
• Dark coffee colored vomiting this morning
Sep 09. 25 Yr old soldier, a case of GERD on H2 Blockers. Returned from village 2 weeks ago. Admitted in Med I X 1 week • Fever X 10 Days- high grade for 1 week
• Pain abdomen X 8 Days – continuous and diffuse. Severe X 2 days
• Initial mild diarrhea X 2 -3 days
• Constipation X 1 week
• Vomiting and abdominal distention X 1 day
• Not passed flatus/ faeces today
• No jaundice, Hematemesis, Melaena
Sep 09. 25 Yr old soldier, a case of GERD on H2 Blockers.
• Had received
• Amoxycillin 1.5 gm per day X 3 Days
• Ciproflox 250 mg 3 times a day X 3 Days
• From Pvt practitioner
General Examination• Slim built. Looks ill and toxic today.
• T 40 degree C, Pulse 90/min low volume,
• BP 80/ 40 mm Hg, Respiration 28/ min
• Dehydration +, Pallor +, Tinge of Icterus +
• Rose spots-Blanching maculo-papular rash over trunk + (fair skinned individual).
• Mutteing incoherently & picking at bed clothes-Delerium +
• No lymphadenopathy, arthritis, petechiae or purpura
Abdominal Examination
• Diffuse tenderness, guarding and distention
• No rigidity.
• Girth has increased by 3 cms
• No free fluid, only gaseous distention
• Liver palpable 2 cm, soft and tender
• Spleen 1 cm, soft and tender
• No other mass
• Bowel sounds feeble
Other Systemic Examination
• CNS: Delerium +, No focal neurological signs, No signs of meningeal irritation
• Respiratory System: Dry mild cough noted. Lungs Clear
• CVS: Heart sounds normal.
Investigations
• Hb- 11 gm/dl• TLC-3200/cc• DLC -N 15%, L 75%, M 10%• Platelets- 80,000/cc • PT/INR – slightly prolonged
• LFT: Bilirubin 2.6 mg/dl, OT 160, PT 220 IU/l• Urea 40 mg/dl, Creatinine 1.8 mg/dl• Blood Glucose: 70 mg/dl• Electrolytes: K+ less
Investigations contd..
• Widal (Paired Sera 1 week apart)
• TO 1: 160 1: 320
• TH 1: 320 1: 640
• AH < 1:80
• BH <1: 80
• Blood Culture after 72 hrs- Non Lactose Fermentergrown _____________________, ABST available
Take Home Messages
• GI Symptoms are the most common presenting complaints in OPD setting
• Great overlap of symptoms in GI Disorders• Overlap with other systems and sites• Severity does not correlate well with seriousness
of disease• Hematemesis and maelena are upper GI
symptoms• Bleeding in the lower GI presents as bleeding PR
and Haematochesia