History taking in abdominal diseases

History taking Family history –Colon cancer –Gallstones

History taking Factors, habits and previous diseases Diet Drugs Alcohol Smoking Transfusion Iv. drug abuse Lifestyle

History taking - summary Abdominal pain Dysphagia Nausea and vomiting Anorexia and unexpected weight loss Abdominal gas Abdominal distension Diarrhea Constipation Gastrointestinal bleeding Jaundice

History taking Abdominal pain Localisation Type Severity Chronology Aggravating or relieving factors Associated symptoms Radiation of pain

Diffuse abdominal pain Peritonitis Intestinal obstruction Irritable bowel syndrome Tense ascites

Acute abdomen Peritonitis Appendicitis Bowel or gastric perforation Gallbladder perforation Intestinal obstruction (ileus) Mesenterial ischaemia Extrauterine pregnancy (ectopic pregnancy) Acute necrotising pancreatitis Biliary colic Renal colic

History taking Other causes abdominal pain Diabetic ketoacidosis Hyperthyroidism Acute intermittent porphyria Hypercalcemia, hyperkalemia Vasculitis Pneumonia Sickle cell crisis Herpes zoster

Radiation of pain Ulcer disease: to the back Biliary pain: to the back, right scapula, right shoulder Pancreatic: band-like, to the back Kidney, ureter: to the genitalia, groin Splenic: left shoulder

History taking Substernal pain Cardiac pain Radiation: left Type: pressing, constricting Aggravating factors: physical activity, stress Relieving factors: nitrates Associated symptoms: dyspnoea, sweating Esophageal pain Radiation : back Type:burning, spasmodic Aggravating factors: body position, eating Relieving factors: antacid Associated symptoms: dysphagia,regurgitation

History taking Dysphagia- difficulty in swallowing Where is the food „hanging up”? oropharyngeal or esophageal Difficulty to swallow liquids? Odynophagia- painful swallowing

History taking Weight loss Is it associated with anorexia? Chronology Severity (significant:> 5% of body weight) Underlying diseases Causes: general disorders: diabetes, hyperthyroidism, chr.infections,malignancy, medications behavioral disorders: anorexia nervosa, depression GI disorders: malignancy, malabsorption, hepatic, biliary, pancreatic diseases

History taking Nausea and vomiting Organic, functional or psychogenic? connection with meals accompanied by weight loss Content of the vomit Factors: taste, smell, color, pH Subtypes: acid : reflux disease, duodenal ulcer bile: bilio-pancreatic diseases undigested food: obstruction of the upper GI faeces (miserere): bowel obstruction (ileus) blood: ie. ulcer, tumor, oes.varix

History taking Abdominal gas Belching, bloating (meteorism), flatulence Causes –Aerophagia (habitual, poor dentition, inadequate chewing, rapid eating) –GI motor dysfunction or obstruction –Malabsorption, maldigestion –Bacterial overgrowth

History taking Bowel movement Factors: frequency, volume, fluidity, color, associated sensations, change in bowel habits, stool calibre Diarrhea > 300 g of stool/day more than 3 loose or watery stools/day Constipation two or less stools/week

History taking Bowel movement Stool alterations –Color - hypocholic, acholic - pleiochromic - bloody –Content - mucus - blood - fat - steatorrhea - undigested proteins - creatorrhea

History taking Bowel movement Constipation –Chronic or recent onset Causes Decreased fluid and/or food intake Functional (irritable bowel syndrome) Medications Hypothyroidism Fecal impaction Rectal or colon cancer Chronic debilitating disease

History taking GI bleeding Classification –Hematemesis - fresh blood - coffee ground –Melena –Hematochezia - blood on the stool - blood mixed with the stool –Occult bleeding

History taking Jaundice Observe it in bright, natural light First time you can observe on the sclerae

History taking Jaundice Important anamnestic factors Color of the skin: overproduction: lemon obstructive: dark-yellow, greenish Color of the stool: overproduction: dark, greenish (pleiochromic) obstructive: hypocholic, acholic Color of the urine: overproduction: cherry-red obstructive: dark, brown Associated symptoms: anemia, pain, fever, hepatomegaly, splenomegaly, ascites

Physical examination of the abdomen 1.Inspection 2.Auscultation 3.Percussion 4. Palpation

Position of the patient

Physical examination Inspection Configurations of the abdomen in the level or above or below the chest apple-type : visceral obesity - cardiovascular risk pear-type : gluteal obesity Abdominal skin striae : white, livid (pink) hernias veins : caput Medusae visible peristalsis visible pulsations scars

Physical examination Abdominal distension Generalised Obesity Pregnancy Ascites Bowel obstruction - ileus Big ovarian cyst Peritonitis Localised Hepatomegaly Splenomegaly Polycystic kidney Gastric distension Inflammatory mass Tumor Obstructed bladder Hernia

Physical examination Auscultation Bowel sounds above the umbilicus or in the RUQ normal: 5-35/min, clicks and gurgles altered: absent: paralytic ileus hyperperistalsis: diarrhea, mechanical bowel obstruction Bruits arterial aortic, renal, iliac arteries Friction rubs spleen, liver, peritonitis Succussion splash normal: above the stomach pathologic: gastric or bowel obstruction

Physical examination Percussion Meteorism Liver span midclavicular line: 6-12 cm midsternal line: 4-8 cm Splenic dullness norm: in the midaxillary line pathological:dullness in the ant. axillary line during inspiration Liver or/and splenic dullness absent: perforation

Ascites shifting dullness

Physical examination Palpation Position Warm hands, short fingernails Approach slowly, avoid quick movements Exemine tender areas at last Watch the patient’s face

Physical examination Palpation 1. Light palpation a. muscular resistance - guarding - defense musculaire b. alterations in the abdominal wall

Physical examination Palpation 2. Deep palpation a. assessing abdominal masses b. assessing abdominal tenderness

Physical examination Palpation Characteristics of an abdominal mass 1. location 2. size 3. shape 4. consistency 5. surface 6. tenderness 7. movable or fixed 8. shifting by respiration

Physical examination Palpation of the liver and spleen Characteristics: 1. size 2. surface 3. edge 4. consistency 5. tenderness (6. liver pulsation)

Physical examination Palpation of the gallbladder Hydrops vesicae felleae Curvoisier’s sign - painless enlargement of the gallbladder due to cancer of the head of the pancreas Murphy’s sign - RUQ pain aggravated by inspiration - acute cholecystitis

Physical examination Palpation of the aorta to the left of the midline normal: < 3-4 cm >6 cm: aortic aneurysm transmitted pulsations: pancreatic or gastric tumor, pseudocyst of the pancreas

Physical examination Rectal digital examination Perianal diseases fistulas, masses Anal alterations hemorrhoids, fisssuras, masses Rectal alterations polyp, neoplasm, ulcer Prostate gland Douglas’s space Stool on the glove