Symptomatology of Gastrointestinal System

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