Diagnostic approach of gastrointestinal diseases

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Diagnostic approach of gastrointestinal diseases Powered By Docstoc
					Common abdominal
Gastroesophageal reflux disease -
   History: heartburn, chest pain, regurgitation,
    acidic taste in mouth, dysphagia, odynophagia,
    extraesophageal: cough, asthma, noncardiac
    chest pain
   Characteristics: increase in laying position
                      night symptoms
                      resolve after antacids
 Physical findings:
 Diagnosis: history, endoscopy,
  pH-monitoring, barium swallow
    Esophageal cancer
   History: dysphagia, odynophagia, pain, vomiting,
    weight loss
   Characteristics: older males, alcoholics, smokers
     progressive dysphagia (solidsofterliquid)
     vomiting just after meals
 Physical finding: general tumor signs
 Diagnosis: barium swallow, endoscopy
Peptic ulcer (duodenal, gastric)
 History: epigastric pain
 Characteristics:
    –   radiates to the back
    –   duodenal: younger people, hyperacid symptoms,
        relapsing disease, more symptoms in spring and
        fall, pain resolves after meals and recur after 2
        hours, night pain, resolve using antacids
    –   gastric: older people, pain just after meals,
        weight loss
    –   smokers
    –   NSAID (aspirin) use
Peptic ulcer (duodenal, gastric)
 Physical finding: epigastric/RUQ tenderness
 Diagnosis: endoscopy or barium study
    gastric ulcer: always indication for endoscopy
    and biopsy
     Peptic ulcer - complications
   Bleeding: melena, hematemesis,
               (rarely: hematochezia)
              rectal digital examination
   Perforation: acute onset
                  very sharp pain (knife-like)
                  liver/splenic dullnes: absent
                  peritoneal signs: defence (guarding),
                   rebound tenderness, no bowel sounds
            Dg: abdominal plain film
                study with water-soluble contrast agent
Peptic ulcer - complications
   Obstruction        a. reversible
                       b. irreversible (scar)
          History: vomiting of undigested food
                    fullness, pain
    Physical signs: succussion splash
       Diagnosis: gastric emptying study (barium)
    Gastric cancer
   History: epigastric pain, fullness, vomiting,
              weight loss
   Characteristics: older people,
                       pain arise at meals
                       dull, progressive pain
   Physical findings:epigastric pain, epigastric mass
                        Virchow’s lymph node
                        general tumor signs
                        occult bleeding
   Diagnosis: barium study, endoscopy, US
Intestinal obstruction (ileus)
1. Mechanical
 History: altered bowel habits, constipation,
  fullness, meteorism, cramping pain, vomiting
  (bile, fecal material)
 Characteristics: variable or progressive
 Physical finding: meteorism
                        increased bowel sound
                        signs of underlying disease
 Diagnosis: plain abdominal x-ray
                searching for the cause
Intestinal obstruction (ileus)
2. Paralytic
 History: signs of the underlying disease,
  constipation, fullness, meteorism, cramping
  pain, vomiting
 Physical finding: meteorism
                       absent bowel sound
                      signs of the underlying
 Diagnosis: plain abdominal x-ray
              searching for the cause
Colorectal cancer
   History: positive family history
             altered bowel habits
             bleeding (occult or manifest)
             late: signs of obstruction
                   cramping pain
                   general tumor signs
   Physical finding:rectal digital examination
                       late: mass, ileus
   Diagnosis: barium study, endoscopy, US
Acute hepatitis
   History: asymptomatic
              after flu-like symptoms jaundice
              anorexia, dyspepsia
              RUQ pain
   Physical finding: jaundice
        enlarged liver: smooth, soft, round, tender
   Diagnosis: liver tests, virus tests
Chronic hepatitis
   History: symptoms: not characteristic
             anorexia, dyspepsia
             later: symptoms of cirrhosis
 Physical finding: enlarged liver (can be normal)
 Diagnosis: US, liver biopsy, serology
Liver cirrhosis
   History: alcohol consumption, chr. hepatitis
    (HBV, HCV, HDV, HGV, autoimmune),
    anorexia, dyspepsia, nausea
    ascites, edemas, portal encephalopathy
    jaundice, bleeding
   Physical findings:
    first: enlarged liver micronodular: alcoholic
                           macronodular: chr. virus
    or autoimmune hepatitis- postnecrotic cirrhosis
     end stage: small liver
Liver cirrhosis
   Physical findings:
  skin: palmar and plantar erythema
        spider naevi
        icterus (scratching)
  testicular atrophy
  signs of portal hypertension:
     ascites (transsudate)
     caput Medusae
 Diagnosis: US, liver biopsy, laboratory
    Biliary colic
   History:pain after fatty meals
             nausea, vomiting (often bile)
             fullness, meteorism
   Characteristics: RUQ-pain, radiates to the back
                       (scapula, right shoulder)
                   mostly females
 Physical finding: RUQ tenderness
 Diagnosis: US
Acute cholecystitis
 History: like in biliary colic + fever
 Physical finding: Murphy’s sign
 Diagnosis: US, laboratory: signs of

 History: like in biliary colic + obstr. jaundice
 Diagnosis: US, ERCP, CT, PTC
Acute pancreatitis
   History: gallstone disease, fatty meal, alcohol
             epigastric pain
             fullness, nausea, vomitus
             hypotony, shock
   Characteristics: band-like, cramping pain
                       radiates to the back
Acute pancreatitis
   Physical findings:
    epigastric tenderness/guarding
    peritoneal signs
    signs of paralytic ileus (meteorism, no bowel
    skin signs: Cullen’s sign-periumbilical
                Grey-Turner’s sign- lumbar
 Diagnosis: pancreatic enzimes, US, CT
Chronic pancreatitis
   History: cramping pain
            anorexia, dyspepsia, nausea, vomitus
            gallstone or alcohol consumption
            weight loss
 Characteristics: pain in the back
                    increases after meals
 Physical finding: epigastric tenderness
                     epigastric mass (pseudocyst)
                     sometimes jaundice
 Diagnosis: plain abd. X-ray, US, CT, ERCP