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SIGNS AND SYMPTOMS OF GIT

DISORDERS
Vidi Orba Busro
DEPARTEMENT OF INTERNAL MEDICINE
DIVISION OF GASTROENTEROHEPATOLOGY
FK UNSRI

DEFINITION

Symptom : Subjective data of patients


complaints
Symptom is the most important thing in
directing or guiding a diagnostic (60%)
Sign : Objective data of physical
findings
Refferences: Adams Physical Dx
Harisson
Signs &Symptoms

Diagnostic Procedure

SOAP
S Subjective (identity, symptoms,
clinical history, genetics)
O Objective (signs, laboratory,
radiologic, etc)
A Assesment (diagnostic & DD)
P Planning (treatment, supporting
examination)

Basic of Symptoms and Signs

Anatomical
- topography
- vascularization and innervation
Physiological
- organ function
- metabolism

RHC

TOPOGRAPHY
Abdominal regions
nine regions system or
four regions system

EPI

RL
UMB
RI

LHC

LL
LI

SP

Organ Function

Esophagus
- swallowing
Gaster & Duodenum
- digestive and absorbtion
Liver
- anabolism and catabolism
- detoxification
- eritropoesis extramedullar
- bile secretion

Pancreas
- hormone secretion
- enzyme secretion
Colon
- reabsorbtion
- faecal formation
Rectal
- faecal reservoar

Symptoms
1.

Abdominal Pain

Abdominal Pain
- the most common symptom
- location, type, cont. or intermitten,
spread, referred
- location depend on topographyc
- due to : GIT ,TUG, Gyn, MSC, & CV
- intermittent pain related to luminar
organ
(colic)
- referred pain depend on innervasion

1.

Types of abdominal pain


- epigastric pain gastroduodenitis,
pancreatitis, Inferior MCI, left liver
abcess, hepatic disorders, lymphoma,
aneurisma aorta
- Biliary colic pain from the right
hypochondrial spread to right back
shoulder gallstone & CBD stone

- Renal colic pain from back CVA


spread to right iliac region
obstructive uropathy
- Right hypochondrial pain hepatic
disorders, gall disorders, pleuritis,
TUG disorders, and colon disorders

- Left hypochondrial Pain gastritis,


pseudocyst pancreas, colon disorders
TUG disorders, pleuritis, and spleen
disorders
- Umbilical pain gastritis, enteritis,
colitis, aneurisma aorta, trombosis of
mesenteric artery
- Right & Left Lumbal pain colon
disorders , TUG disorders, psoas abcess

- Right Iliac pain appendicitis,


colon disorders, psoas abcess, PID,
ovary cyst, ileitis term., TUG dis.
- Left Iliac pain colon disorders,
psoas abcess, PID, ovary cyst, TUG
disorders

- Suprapubic pain cystitis & bladder


stone, gynaecologic disorders,
prostat
disorders, colo-rectal disorders
- Whole abdomen pain peritonitis,
muscle pain, gastroenteritis, colitis

2. Abdominal Distention

Due to: gas, fluid, mass,


organomegali
With or without pain ?
Acute, recurent, or chronic ?
Bowel or micturia alteration ?
Organ involved: GIT, TUG, Heart

3. Dysphagia

Difficulty swallowing
Due to pain, obstruction, abn. peristalsis
or impaired reflex (nerve)
Organ involved esophagus or
oropharynx
Most common case: Stricture esophagus
malignancy, GERD, multiple sclerosis

4. Odinophagia

Pain of swallowing
Organ involved esophagus
Due to inflammation process

5. Heartburn

Burn sensation on the front chest


Due to reflux esofagitis
DD/ angina pectoris, intercostal
neuralgia, pulmonary problem,
psychosomatic
Confounding factor: asthma,
dyspepsia, no cardiovascular risk
factor, obesity

6. Hiccup or Singultus

Involuntary spasmodic contraction


of the diaphragm followed by
sudden closure of glottis
Due to increase of intracranial
pressure, abdominal distention,
gastric dilatation or inflammation,
and renal failure, decrease serum
levels of carbondioxide

7. Vomitus &
Regurgitation

Reflux of gastric contents


The difference with or without
contraction
Involved vagal mechanism
Non specific all of GIT disorders

8. Bloating

Full sensation of stomach


Due to inflammation, gastric
emptying disorders, gastric mass,
Increase of gastric pressure,
increase of gas production, full or
partial obstruction

9. Hematemesis

Bleeding of upper GIT (lig. treitz)


Due to variceal rupture, ulcer,
erotion, mass
Organ involved esophagus,
stomach, & duodenum
Life threatening symptom

10. Melena

Black bloody stool from upper GIT


Black color is due to oxidation of
Hb
Caused and organ involved
similar to hematemesis
Life threatening symptom

11. Diarrhea

Waterry stool more than 3 x/day


Acute or chronic ? ( 2 weeks )
Due to reabsorbtion impairment
(osmotic, toxin,etc) or
hyperperistaltic
(hyperthyroid)
Organ involved Intestinal and
colorectal

12. Constipation

No defecation more than 3 days


Due to obstruction,
hypoperistaltic, inflammation,
medication
Organ involved Colorectal

13. Hematoschezia

Fresh red bloody stool


Due to lower GIT
Haemorhoid is the most common
cause of hematoschezia
Acute,reccurent, or chronic ?
Bowel habit alteration ?

Signs

From physical findings


Most common in hepatobilliary
disorders
General : vital sign
Specific : inspection, palpation,
percusion, and auscultation
Gentle
Right side of patients

1. Mental Change

Most common in end stage of


cirrhosis or severe hepatic
disorders
Called as encephalopathy hepatic
Due to false neurotransmitter
(aromatic amino acids, ammonia)
Sometimes accompanied by
flapping tremor

2. Icteric or Jaundice

A yellow discoloration of the skin, mucous


membranes, or sclera of the eyes
Signs of excessive levels of conjugated or
unconjugated bilirubin in the blood
Type : Prehepatic, Hepatic, and
Posthepatic
Commonly accompanied by pruritus
because bile pigment damage sensory
nerve (hepatic or posthepatic jaundice)

Ikterik

jaundice

Tea dark colored urine, clay colored stools


always accoppany obstructive or
posthepatic jaundice
Prehepatic jaundice hemolysis
Hepatic jaundice hepatic disorders,
congestive liver (heart), systemic
inflammation (sepsis, lupus), malignancy,
and drugs
Posthepatic jaundice CBD stone,
malignancy of billiary system, lymphoma

3. Gynecomastia

Occuring only in males


Increased breast size due to
excessive mammary gland
development
Most common in cirrhosis
Failure to inactivate circulating
estrogen

4. Spider
Nevi/Angioma

A fiery red vascular lession with


an elevated central body and a
surrounding flush
Most common in face, neck, and
chest
Related with cirrhosis and
hyperestrogenemia (pregnancy)

5. Palmar Erythema

Local vasodilatation along palmar


side
Most common in cirrhosis
Mechanism is unknown

6. Ascites

Accumulation of fluid in abdominal cavity


Due to decrease of osmotic pressure
(hypoalbumin) or increase of hydro-static
pressure (portal hypertension)
Signs shifting dullness, undulation
Nonspecific sign
Most common in cirrhosis, gynaecologic
dis., severe diseases, peritoneal
tuberculous, renal and heart problem

Ascites

ascites accumulation of fluid in the abdominal cavity

7. Meteorismus

Accumulation of gas in abdominal


cavity
Hypersonor percusion
Bowel sound ? Metalic sound ?
Pain ? Flatus ? Bowel Habit ?
Due to electrolyte imbalance, drug,
inflammation, total or partial
obstructive

8. Pain palpation

Depend on tophographic
Types: Murphys sign, Ludwigs
sign, CVA percussion pain,
epigastric pain, Mc Burtneys
pain, defanse muscular,
suprapubic pain

9. Hepatomegaly

Hepatic enlargement more than


normal ( how the border?)
Confirmed by palpation, percussion,
and sonographic
Due to systemic or hepatic
problems
Important things size,
consistency, and pain

liver enlargement, portal hypertension

LIVER SPAN
MCL

PERCUSSION

NL < 12-13 CM

PERCUSSION

2-3 CM DURING
INSPIRATION AND
EXPIRATION

SCRATCH TEST

COPD

PALPATION

LIVER SPAN MAY VARY BETWEEN


OBSERVERS DEPENDING UPON
WHERE THE MCL IS DETERMINED
JAMA 1994;271:1859-1865

PALPATION

FLEX KNEES AND HIPS IF POSSIBLE


BEGIN LOW ON ABDOMINAL WALL AND MOVE HAND CEPHALAD, HAVE
PATIENT TAKE A DEEP BREATH
NOTE CONSISTENCY (NODULES, SMOOTH) AND CONTOUR IF THE
LIVER EDGE IS FELT
NOTE IF THERE IS ANY PAIN WITH PALPATION
AUSCULTATE
MOSBYS GUIDE TO THE PHYSICAL EXAMINATION, 3RD ED. 1995

10. Splenomegaly

Enlargement of spleen more than


normal (how the border?)
Due to infection, trauma, portal
hypertension, neoplastic,
hematologic disorders
Confirmed by palpation and
sonograph

11. Mass palpation

Depend on topographic (similar to


abdominal pain)
Important things size,
consistency, mobility, and pain
Confirmed by sonograph,
radiograph, and endoscopy

12. Flapping Tremor

Patognomonis sign of
encephalopathy hepatic
Tremor of wrist joint after full
extension

13. Pitting Edema

Accumulation of fluid in subcutis


especially in plantar pedis
Due to hepatic, renal, heart,
malnutrition, blood vessel, and
systemic inflammation

Case Simulation

A young lady, married, 32 yo,


came to hospital with chief
complaint of epigastric pain
localized
What questions should you ask to
this patient?

This lady have a fever since 1


weeks ago, abdominal distention
in epigastric, vomitus, history of
bloody diarhea, no history of
dyspepsia before
What examinations should you
perform to this patients?

From examination, there are


icteric, pain and palpable mass in
epigastric, dark tea color urine, no
cley-color stool, no defanse
muscular
What working diagnostic and
differential diagnostic are possible
in this patient?

The working dignostic in this patient is


left lobe hepatic abcess
The differential diagnostic are
pancreatic neoplasm, gastric mass,
pseudocyst of pancreas, left lobe
hepatoma, colon mass, lymphoma,
aortic aneurism.
What are next examinations you
suggested to confirm a diagnostic ?
What is the treatment ?