The gastrointestinal system

Raed Alsulaiman,MD
Assist.Prof.King Faisal University
Consultant Gastroenterologist
Department of medicine
King Fahad Hospital University
 The gastrointestinal history
presenting symptoms
Abdominal pain Bleeding
Appetite and/or Jaundice
weight change Dark urine,pale stool
Nausea and/or Abdominal swelling
vomiting Pruritis
Waterbrash Fever
Dysphagia
Disturbed defecation
 Abdominal pain
Three broad categories
1. Visceral pain:
 when hollow abdominal organs distended or stretched
 Difficult to localize
 Palpable near the midline
 Varies in character: burning, cramping,or aching
 If severe may be associated with
sweating,pallor,nausea,vomiting and restlessness
Visceral pain
 Abdominal pain
2.Parietal pain
 Originates in the parietal peritoneum
 Caused by inflammation
 More severe, steady aching pain and
more localized
 Aggravated by movement and coughing
 Patient prefer to lie still
 Example :appendicitis
 Abdominal pain
3. Referred pain
 Felt in more distant
sites
 Usually well localized
 Pain my be referred to
the abdomen from the
chest,spine ,or pelvis
 Duodenal or pancreatic
…..back
 Biliary tree…….right
shoulder
 Pleurisy or MI…..
Upper abdomen
 Abdominal pain
analysis
1. Character: colicky Peptic ulcer
,burning,steady Cancer of the stomach
2. Frequency Acute pancreatitis
3. Duration Chronic pancreatitis
4. Site Pancreatic ca
5. Radiation Biliary colic
6. Severity Acute cholecystits
7. Aggravating and Acute diverticulitis
relieving factors Acute appendicitis
8. Associated symptoms Acute intestinal obstruction
Mesentric ischemia
 Appetite or weight change
Anorexia: loss of appetite
Anorexia and weight loss :malignancy or
depression
Weight loss and increased appetite:
malabsorption,hypermetabolic state
Anorexia and weight gain: hypothyroidism
Increased appetite and weight gain:
cushing’s syndrome,hypoglycemia
 Nausea and vomiting
Retching /vomiting/regurgitation
Color ? Clear/mucoid/yellowish/blood
Smell? Fecal odor
Timing of vomiting?
How much? Tea spoon,cupful
Complication of vomiting
 Aspiration
 Dehydration
 Nausea and vomiting
causes
Gastrointestinal disrorders
Pregnancy
Diabetic ketoacidosis
Adrenal insufficiency
Uremia
Hypercalcemia
Liver disease
Drugs
Induced but without anorexia:anorexia/bulemia
nervosa
 Heartburn
waterbrash
Sense of burning or warmth that is retrosternal and
may radiate from the epigastrium to the neck
It originate in esophagus
It suggests gastric acid reflux into the esiophagus :
GERD ,often precipitated by a heavy meal ,lying
down,or bending forward
Should be differentiated from pain of coronary
artery disease
Dysphagia:difficulty swallowing
Solid? liquid?
Difficulty initiating swallowing? Oropharyngeal
dysphagia
Intermittent ?
Progressive?
Location? Pointing to the throat not specific
,pointing to the chest suggests esophageal
disorder
 Causes of dysphagia
Mechanical obstruction Neuromuscular
• Intrinsin(within esophagus)
 Achalasia
 Esophageal stricture
 Esophageal ca  Diffuse esophageal
 Pharyngeal web spasm
 Lower esophageal ring  Scelroderma
 Foreign body
• Extrinsic (outside
 Myasthenia gravis
esophagus)  Myotonia dystrophica
 Goiter /mediastinal tumor
 Bulbar/pseudobulbar
pulsy
Odynophagia :painful swallowing
It occurs with any sever inflammatory
process involving the esophagus
Infectious esophagitis
Peptic ulceration of esophagus
Caustic damage of esophagus
Esophageal perforation
 Diarrhea
Frequency/consistency Nocturnal diarrhoea
Acute , chronic or suggests an organic
recurrent cause
Descriptive terms: Aggravating :diet
 are the stools greasy or Tenesmus:intense urge
oily? with straining but little or
 Frothy? foul smelling? no result
 Floating on the surface or New travel?dugs?
difficult to flush? Family history
 Accompanying by Associated symptoms
mucus ,pus ,or blood?
 Diarrhea
1. Secretory diarrhoea

2. Osmotic diarrhoea

3. Abnormal intestinal motility

4. Exudative diarrhoea

5. Malabsorption
 Constipation
What the patient means?
• Decrease in frequency?
• Hard or painful stool?
• Need to strain hard?
• Sense of incomplete
defecation?
• Shape of stool ? Pencil-like
stool seen in sigmoid ca
• Obstipation: in intestinal
obstruction
 Constipation
causes
Life activities and habit
Irritable bowel syndrome
Mechanical obstruction:
 Rectal or sigmoid ca
 Fecal impaction
 Painful anal lesion
 Drugs
 Metabolic /neurological disorder
 GI bleeding
Hematemesis
 Coffee-ground or red blood
Melena
 Black ,tarry stool
 At least 60 ml of blood in GI
Hematochezia
 Indicate lower GI or massive upper GI
bleeding
 Jaundice/icterus
Yellow discoloration of the
skin and sclera
Mechanisms:
 Increased production of
bilirubin
 Decreases uptake of
bilirubin by the
hepatocytes
 Decreased the ability of
the liver to conjugate
bilirubin
 Decreased excretion of
bilirubin
 Jaundice/icterus
Color of urine?
Color of the stool ? Acholic stool
Skin itch ;pruritus?
Abdominal pain?
Recurrent?
Risk factors for liver disease?
 Hepatitis
 Alcholic
 Drugs
 Hereditary
 Abdominal distension
Fat
Fluid
Fetus
Flatus
Faces
‘filthy, big tumor
 Past history
Surgical procedure
History of PUD or IBD
Drug history:
 NSAID /aspirin
 Paracetamol overdose
 Halothane/phenytoin/cholthiazide
 Rifampicine,sulpha drugs
 Anabolic steroid
 Social history
Occupation
Recent travel
Alchol history
Contact with jaundiced patients
Sexual history
Any injections(IV drug abuse ,tattooing)
 Family history
Bowel cancer

IBD

Splenectomy,anemia ,jaundice

Liver disease
The gastrointestinal system
examination
Raed Alsulaiman,MD
Assist.Prof.King Faisal University
Consultant Gastroenterologist
Department of medicine
King Fahad Hospital University
 Sequence of examination
General appearance

Vital signs

Hand Abdomen /genitalia

Upper arm/lower arm

Head and neck

Chest/heart
 General appearance
The physical attitude :

 Peritonitis: lie still

 Abdominal colic: restless and rolling in bed

 Congestive heart failure: orthopnic

 Confused: hepatic encephalopathy

 General appearance
nutrition state
Physique:
 Appearance consistent with patient age
 Thin / obese
 Malnourished:
 Presence and distribution of body fat
 The muscle bulk
 The presence of oedema
Assessment of nutritional state
malnutrition
Wasting of temporalis
muscle
Dry cracked skin
Loss of scalp and
body hair
Poor wound heeling
Wasted limb muscle
Hyporeflexia
Atrophy of
subcutaneous fat
 Assessment of nutritional state
Skin fold thickness
• Biceps
• Triceps: most Standard 80% 60%
common site
• Infra-scapular Adult male 12.5 10 7.5

• Supra-iliac region
Adult female16.5 13 10

Nutrtional Normal Moderate Severe

state nutrition dipletion depletion
Assessment of nutritional state
Body mass index (BMI)

Normal BMI=18-25 BMI= weight(Kg)/height(m)2

Overweight =25-29.9
Obesity>30
Morbid obesity>40
BMI<18 require nutritional advice
 General appearance
SKIN
pallor
Site: Cause
 Skin  Severe anemia
 Mucous membrane  Shock
 Mouth  Hypopituitarism
 Conjunctiva  Person with thick or
opaque skin
 General appearance
SKIN
Jaundice
in natural daylight
Site
 Skin
 Sclera
 Hard palate
Cause
• Hypebilirubinemia
• Conjugated unconjugated
 General appearance
SKIN
Pigmentation
 Chronic liver disease

 Malabsorbtion
celiac disease

Dermatitis herpitiformis
 General appearance
SKIN
:

Acanthosis Nigricans :Telangictasia

 General appearance
The hands/feet

Leukonychia Clubbing

Palmar erythema
Clubbing
 General appearance
The hands/feet

Bruising Dupuytern’ contracture

Petechiae
 General appearance

Muscle wasting
Spider nevi
D.Dx :
Venous star
hereditary telengictasia
 General appearance
The face
Eyes
Kayser-Fleisher rings
 Iritis

Xanthelasma

Parotid
 General appearance
The face

The mouth
 The teeth and breath
Causes of fetor
Faulty oral hygiene
Causes of gum hypertrophy Fetor hepaticus
Phynetoin Ketosis
Pregnancy Uremia

Scurvy Alchol
Paraldehyde
Ginigivitis
Putrid(chest infection)
Leukaemia(monocytic Cigarettes
 General appearance
The face
The mouth The Tongue
Causes of pigmented lesions in the Coating over the tongue: thickened epi
mouth with bacterial debris and food particle

Heavy metals Lingua nigra(black tongue):elongation of

Drugs:antimalaria papillae over the posterior part

Addison’s disease Geograpgic tongue:can be a sign of

Peutz-Jeghers syndrome Riboflavin deficiency

Malignant melanoma Leukoplakia :premalignant .?Sore

teeth,smoking,spirits,sepsis ,syphilis

Glositis :smooth tongue.Deficincy of

iron,folate and B12

Macroglossia:Down’s syndrome
acromegaly,amyloid,tumor
 General appearance
The face
Cause of mouth ulcers
1. Aphthous
2. Drugs (gold,steroid)
3. Trauma
4. Gastrointestinal disease :CD,UC
5. Rheumatological disease: Behcet’s disease
6. Erythema multiforme
7. Infection: viral-herpes zoster ,Herpes simplex
Bacterial: Syphylis
 General appearance
Neck and chest
Cervical lymph node : left suraclavicular
lymph node with gastric ca (Troisier’s sign)
Gynaecomastia

Spider nevi
Campbell de Morgan spots
Physical Exam
Physical Exam
 The abdomen
Good light
Relaxed patient
Full exposure: from
above the xiphoid
process to the
symphysis pubis
The groin should be
visible
The genitalia should
remain draped
 Techniques of examination
Check that the patient has an empty bladder
Supine position, with a pillow under the head
and perhaps another under the knees
Keep the arms at the sides
Before you begin palpation ask the patient to
point any area of pain
Warm your hands and stethoscope
Watch the patient face for discomfort
 Techniques of examination
Inspection

Palpation

Light palpation

Percussion
Deep palpation

Organ palpation
Auscultation

Palpation of groin
Abdominal areas
Abdominal areas
Inspection
 Inspection
Lay the subject supine
General inspection of the
abdomen
 symmetry of its shape
 the presence of markings
and scars.
 the shape (contour)
 movement of the
abdomen.
 Inspect the groin
bilaterally and check for
cough impulse
 Inspection normal findings
Skin surface
Free of abnormal
discoloration, new
growth, striae, surgical
scars, or prominent veins;
Seborrhoeic warts and
hemangiomas (Campbell
del Morgan spots) may
be normal findings in
geriatric patients;
Umbilicus is sunken
 Inspection normal findings
Shape
Symmetrical in shape
Scaphoid or flat in young
patients of normal weight
slightly full but not
distended in older age
group due to poor muscle
tone or in subjects who
are mildly overweight
 Inspection normal findings
Movement
Rises and falls rhythmically with
inspiration and expiration respectively
Pulsation of the abdominal aorta may be
seen in the epigastrium of a slender
person
Cough impulse
No cough impulse should be seen along
the inguinal canals
 Inspection abnormal findings
Skin surface
Striae :recent weight loss except in postpartum females
Scars :previous surgical operations
Prominent veins
1. inferior cava obstruction
2. portal hypertension;
Umbilicus is flat or protruding
1. Umbilical hernia
2. Abnormal intra-abdominal fluid collection (e.g., ascites) or
masses.
3. Tumor
Abdominal scars
Abdominal veins
 Abnormal findings
Shape or contour
A sunken abdomen with prominent ribs and bony pelvic landmarks
is seen in emaciated patients
Symmetrical distension is seen when intra-abdominal content is
increased (adipose tissue in obesity, gravid uterus, increased bowel
contents like gas or fluid in bowel obstruction, peritoneal fluid in
ascites);
Gross enlargement of the liver may be seen as a bulge in the right
upper quadrant;
Gross enlargement of the spleen may be seen as a bulge in the left
upper quadrant;
Enlarged kidneys may be seen as bulges in the lumbar regions in
rare occasions;
An enlarged urinary bladder or uterus may be seen as a central
rounded suprapubic swelling rising out of the pelvis
 Abnormal findings
Movement
Abdominal movement associated with respiration may
be minimal or absent in peritonitis;
Gastric peristalsis may be seen across the upper
abdomen from left to right in gastric outlet obstruction;
In bowel obstruction, vigorous small intestinal peristalsis
may be seen in the center of the abdomen
Cough impulse
 Inguinal hernia
Palpation
 Palpation
Light palpation
1. Abdominal muscle tone
2. Tenderness
3. rebound tenderness..
When muscle tone is increased, there is resistance to
depression of the abdominal wall by the palpating hand; it
commonly accompanies the presence of tenderness.
Tenderness is a sign that the peritoneum under the abdominal
wall or the underlying organ is inflamed.
Rebound tenderness is pain elicited when pressure applied to
the abdomen wall by the palpating hand is suddenly released. It
is a sign that the underlying peritoneum is inflamed.
 Palpation
Light palpation
The normal abdomen
feels soft to palpation;
There should be no
tenderness or
rebound tenderness
 Palpation
Light palpation: abnormal findings
Failure by the patient to relax.
 Ask the patient to take slow deep breaths
can also help.
Increased in muscle tone, tenderness, and
rebound tenderness are indications of
organic disease.
Guarding : voluntary or involuntary
Rigidity: involuntary
 Palpation
Deep palpation
The purpose of deep palpation is to feel
for organs in the depth of the abdominal
cavity.
 Palpation
In slender patients with a
soft abdomen the
following may be
palpable:
the caecum in the right
iliac region
the transverse colon in
the epigastrium,
the colon in the left iliac
region if they are filled
with feces
the pulse of the aorta in
the epigastrium.
Deep palpation ;abnormal findings
Lesions on the abdominal wall can be
distinguished from those inside the
abdomen by asking the patient to tighten
his abdominal muscles (e.g., by asking the
patient to lift his head off the pillow and
look at his toes): those on the abdominal
wall will remain palpable while intra-
abdominal lesions are not.
Description of abdominal mass
Location (in the wall of or inside the abdomen; also its position
according to the quadrants or regions of the abdomen and its
relation to other organs).
Shape (round, oval, irregular, etc).
Size (in terms of diameters in at least 2 of the 3 dimensions).
Consistency (hard, firm, rubbery, soft, fluctuant, indentable,
pulsating).
Surface texture (smooth, nodular, irregular, etc).
Mobility (free or fixed to adjacent tissue, movement in relation to
respiration).
Tenderness (tender or non-tender).
Pulsation
 If mass is pulsatile ?
If it is expansile
1. aortic aneurysm
2. a fluid filled cyst on top of the aorta

it is not expansile, the palpated mass is

on top of the aorta.
Liver palpation
 Liver palpation
Start in the right iliac
fossa
If liver edge is felt
describe:
 Size
 Surfce
 Edge
 Consistency
 Tender
 Pulsatile
 ?bruit
 Liver palpation
Normal findings
The liver can descend for up to 3 cm on
deep inspiration and its edge can be,
though not always, palpable just below the
right costal margin without being enlarged
in many normal subjects.
The normal liver edge is sharp, smooth,
soft, and flexible.
The normal gallbladder is not palpable
 Differential diagnosis in Liver
Hepatomegaly Massive
palpation
Moderate Mild
Metastasis Haemochrmatosis Hepatitis
Alcholic liver Haematological Biliary obstruction
disease with fatty disease(CLL,lymphom Hydatid disease
infiltration a)
Fatty liver in DM HIV
Myeloproliferative
Infiltration e.g The massive and
disease
amyloid moderate causes
Right heart failure the massive causes
Hepatocellular ca

Firm and irregular Cirrhosis Metastatic disease Hydatid disease

granuloma
Tender liver Hepatitis Right heart failure Hepatic abcess
HCC
Pulsatile live Tricuspid HCC Vascular
regurgitation abnormalities
 Gallbladder
courvoisier’s low: With jaundice
Palpable gallbladder in 1. Carcinoma of the head of
the presence of pancreas
obstructive jaundice is 2. Apulla of vater Ca
due to carcinoma of the
head of pancrease until Without jaundice
proven otherwise. .
Murphy’s sign :
inspiratory effort may be 1. Mucocele or empyema
arrested abruptly due to 2. Gallbladder ca
pain. It indicates acute 3. Acute cholecystitis
cholecystitis
Spleen palpation
 Spleen palpation
The normal spleen in a
healthy subject is not
palpable
If spleen is not palpable in
supine position ,ask the
patient to turn into right
lateral position and palpate
for the spleen
(splenomegaly) it does not
appear subcostally until it
is 2 times normal size.
 Splenomegaly
Splenomegaly Massive Moderate Small
CML Portal hypertension Haemolytic
Myelofibrosis Lymphoma anemia
Malaria Leukemia Megaloblastic
anemia
Kala azar Thalassemia
Primary storage disease Infection:
lymphoma Viral(hepatitis)
of spleen Bacteria(SBE)
Connective tissue
disease: e.g
rheumatoid
arthritis,SLE
,polyarteritis nodosa
Infiltartion:
Amyloid,sarcoid
 Kidney palpation

Bimanual technique
Ballottement technique
Right kidney
 Right kidney
The lower pole of the right kidney may be felt
Pounding on the costo-vertebral angle should not
cause pain.
Abnormal findings
Features of any abnormal mass should be
described: location, shape, size, surface texture,
consistency, mobility, and tenderness.
Tenderness at the costo-vertebral angle means
infection or inflammation of the kidney
 Spleen or left kidney?
spleen Kidney
no palpable upper border Palpable upper border
can’t get above it can get above it
One or two notch No notch

Moves inferomedially with inspiration Moves inferiorly with inspiration

Nor ballotable Ballotable

Dull percussion note over the spleen Resonant percussion note over the
kidney
Friction rub may be occasionally heard Friction rub never heard
 The aorta
Upper abdomen left
to the midline
Diameter should not
exceed 3.0cm
 Palpation of the groins
femoral pulses , abnormal lymph nodes and hernias

Stand to one side of the subject and palpate the right and left
femoral artery, which lies just below the inguinal ligament mid-way
between the anterior superior iliac spine and the pubic symphysis.

Feeling with the fingers, palpate along the femoral artery and the
inguinal canal on both sides for abnormal or enlarged lymph nodes.

Place the palmar surface of the fingers of one hand over the
inguinal canal on one side and the same with your other hand on
the other side. Do not cross your arms. Check for expansile (cough)
impulse in the inguinal canal while the subject coughs.
Percussion
 Percussion

Technique of percussion
 Percussion of the abdomen
Percussion is used to:
1. delineate the borders of the liver,
2. the enlarged spleen,
3. or other masses.
4. to determine if abdominal distention is due to gas-filled
bowels or accumulation of fluid (a condition called
ascites).
When percussion is practiced, always proceed from a
tympanitic or resonant site towards a dull or flat site and
position the middle finger that receives the strike parallel
to the anticipated border and not perpendicular to it.
Liver percussion
 Spleen percussion
Traube’s space
 Left costal margin, left
6th intercostals space
and left midaxilary
line
 Spleen percussion
Splenic percussion
sign
 Ascites
Shifting dullness
Ascites
Fluid thrill
 Appendicitis
Muscular rigidity
Rebound tenderness
Rovsing’s sign
Referred rebound tenderness
Psoas sign
Acute cholecystitis
Murphy’s sign
 Auscultation

1. bowel sounds produced by

peristaltic activities
2. Vascular sounds
3. Friction rub
 Auscultation
Listen for bowel sounds for at least 30 seconds
over the right lower quadrant
succussion splash : splashing noise due to
wave-like motion of fluid in an air-filled cavity
Steady the diaphragm of the stethoscope over
the right upper quadrant with one hand. Shake
the abdomen from side to side vigorously at the
same time with the other free hand and listen for
splashing sound
 Auscultation
Listen for bruits
1. The abdominal aorta (A) at the
epigastrium;
2. The renal arteries (R) at the
hypochondrium bilaterally or
the costovertebral angle at the
back bilaterally;
3. The iliac arteries (I) in the
center of each lower quadrant;
4. The femoral arteries (F) just
below the mid-point of the
inguinal ligment bilaterally.
 Normal findings
Normal bowel sounds are intermittent and heard
as bursts of continuous sound every 5 to 10
seconds.
Succussion splash may be heard in normal
subjects for up to 3 hours after a meal.
No arterial bruit is heard in the normal abdomen.
No venous hum is heard in the normal abdomen.
 Abnormal findings
Acute bowel obstruction, bowel sounds are exaggerated
in intensity due to increase in peristaltic activity.
(borborygmi) •
Peritonitis bowel peristalsis stops (paralytic ileus) and
the abdomen is silent. •
Succussion splash heard in a subject more than 3 hours
after a meal is a sign of gastric outlet obstruction..
Systolic bruit stenosis of the underlying artery.
Venous hum is rarely heard. When present, it is a sign of
venous collaterals developed secondary to portal
hypertension (cruveilhier-Baumgarten syndrome)
 Rectal examination
Abdominal examination is not complete without the
performance of rectal examination
 Rectal prolapse
 Fistula-in ano
 Skin tag
 Anal fissure
 Condylomata accuminata
 Thrombosed external haemorrhoid
 Anal ca
 Pruritus ani
 Excoriation from diarrhea
 Rectal examination
Palpate the anterior wall of rectum for prostate in male
and cervix in female
Tenderness :
 Anal fissure
 Ischciorectal abcess
 Recently thrombosed pile
 Proctitis
 Anal ulcer
 Always inspect finger for blood
 To study the phenomena of
disease without books is to sail
an uncharted sea, while to study
books without patients is not to
go to sea at all