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SYMPTOMS & SIGNS
IN GI PROBLEMS
(History & Physical)
Dr.B.SELVARAJ MS;Mch;FICS;
Professor of Surgery
Melaka Manipal Medical college
Melaka 75150 Malaysia
SYMPTOMS IN GI
PROBLEMS
(History Taking)
Dr.B.SELVARAJ MS;Mch;FICS;
Professor of Surgery
Melaka Manipal Medical college
Melaka 75150 Malaysia
SYMPTOMS IN GI
PROBLEMS
• Pain abdomen
• Difficulty in swallowing- Dysphagia
• Vomiting
• Heartburn- Retrosternal pain- Pyrosis
• Indigestion
• Change in bowel habits-Constipation/Diarrhea
• Loss of appetite/ Loss of weight
SYMPTOMS IN GI
PROBLEMS
PAIN ABDOMENBasic questions you would ask in Abdominal pain
• When did the pain start?
• Where is it, show me?
• Have you ever had it before?
• Did it come on suddenly or
gradually?
• Does it go anywhere else? Show me.
• How bad is it, worst you have ever
had, severe, very severe, mild,
moderate, just an ache (do not use
x/10 unless you define 10)?
• Is it the same all the time?
• Have you had time completely free of
pain since it started?
• Is it constant or comes in waves?
• Is it getting worse?
• What makes it better, e.g. lying
still/painkillers?
• What makes it worse, e.g. moving
about?
• Have you got any other symptoms with
it, give examples,
e.g. vomiting/fever
SYMPTOMS IN GI
PROBLEMS
Difficulty in Swallowing-
Dysphagia
Basic questions you would ask in Dysphagia
• How long have you had the problem?
• Describe what it is like?
• Have you had it before?
• Did it come on gradually or suddenly?
• Is it becoming worse?
• Do you have difficulty with solids and/
or liquids?
• Which came first?
• Does the food seem to stick. Show me
where?
• Have you been vomiting, what, etc.
(see below)?
• How is your appetite?
• Have you lost weight?
• Plus, all the other GI protocol
questions
• Plus, do you feel anything else wrong
with you at present.
SYMPTOMS IN GI
PROBLEMS
VOMITINGBasic questions you would ask in Vomiting
• When did the vomiting start?
• What do you vomit?
• Is it food/water/bile/greeny
stuff/acid/blood?
• If food, is it food you have just eaten
or old food?
• If it is blood, how do you know?
Amount, color, clots, coffee grounds.
• How often do you vomit?
• Do you feel sick (nauseated) all the
time?
• Does anything bring the vomiting on
(worse)?
• Does anything make it better?
• Does it shoot out with great force
(projectile)?
• Any coughing or choking?
SYMPTOMS IN GI
PROBLEMS
Heartburn- Retrosternal Pain-
Pyrosis
Basic questions you would ask in Retrosternal Pain
• Describe it to me .
• How long have you had it?
• Have you had it before this episode?
• Did it come on gradually or suddenly?
• Is it becoming worse?
• What makes it worse (e.g. lying down
in bed, bending over, certain types of
food and drink-spicy food/
alcohol/coffee)?
• What makes it better ( sleeping, sitting
up, avoiding certain drinks or food,
medications)?
• Do you get any acid reflux-acid or
water coming into your mouth, describe
this please (distinguish acid reflux and
water-brash).
• Do you have any difficulty swallowing?
Describe.
• Do you have any pain behind the chest
bone? Describe.
• Do you vomit?
• Do you have indigestion?
• Have you put on weight recently?
SYMPTOMS IN GI
PROBLEMS
INDIGESTIONBasic questions you would ask in Indigestion
• Do you have any indigestion, if says 'yes'?
• Ask what do you mean by this, if says 'no; ask: do
you have any discomfort or pain in your tummy
after eating?
• Where is the discomfort, show me (pointing sign
of DU)?
• When do you get it-before meals/ after meals?
• Does it wake you at night (DU), what do you do
about it, e.g. get up have some milk and a biscuit
(DU)?
• How often do you get it, e.g. every day?
• Have you had it before?
• Have you seen your GP about it or been
investigated in hospital (e.g. endoscopy)?
• What did they say was wrong with you?
• What makes the indigestion worse/better?
• Have you been vomiting any blood?
• How is your appetite; have you lost
weight?
• Do you take any medications for it
(define)?
• Are you taking aspirin/NSAIDs/ steroids/
herbal medications?
SYMPTOMS IN GI
PROBLEMS
Altered Bowel HabitsBasic questions you would ask in Altered Bowel Habits
• Has your bowel habit changed
recently?
• If patient does not appear to
understand-Explain.
• Have you developed diarrhea or
constipation recently (means different
things to different people)?
• Define their normal bowel habit.
• Define what it has changed to, e.g.
normal is x 1 per day now is x 3 per day.
• If has diarrhea-define content, color,
offensive, blood/floats (see set of
questions below).
• If has constipation-is it constipation or
incomplete evacuation? or even tenesmus
(see below set of questions)?
• Have you passed any blood or slime?
Define both.
• Have you had any abdominal pain or
weight loss?
• On any drugs ( e.g. antibiotic)?
SYMPTOMS IN GI
PROBLEMS
Altered Bowel HabitsBasic questions you would ask in Diarrhea
• Frequency of defecation (>x3 =
abnormal).
• Recent or present for long time.
• Solid/liquid/mixed. Bulky may be
steatorrhea.
• Color: Black (melena), red (blood),
pale (steatorrhea,obstructive jaundice),
silver (because of mixture of melena
and fatty stool in tropical sprue,
carcinoma (Ca) of ampulla of Vater).
• Pus or mucus.
• Smell-very offensive, may be
infective/melena.
• Floats/ difficult to flush away, may be
steatorrhea.
• Any other symptoms, e.g. vomiting.
• Been abroad recently.
• Anyone else in family with it
(gastroenteritis).
• NB: Some gastroenterologists divide by
physiological cause into secretory, osmotic,
exudative, malabsorption (not very useful
in practice).
SYMPTOMS IN GI
PROBLEMS
Altered Bowel Habits
Basic questions you would ask in Constipation
• What do you mean by constipation-
infrequent bowel action or very hard
motion or difficulty in evacuation?
• Is this a new symptom or long
standing?
• If recent, define 'change': Normal
bowel habit versus old bowel habit.
• Any blood or mucus?
• Incomplete emptying-have to go
again-is a symptom of pelvic floor
descent or rectal cancer- Tenesmus
• Any incontinence-overflow or
otherwise?
• Painful almost continuous urge to
defecate is tenesmus (rectal equivalent of
urinary strangury) indicates inflammation
or tumor involving anal sphincters.
• Other GI symptoms, e.g. abdominal
pain/distension.
• On any drugs, e.g. codeine.
• Alternating diarrhea + constipation,
some say symptom of tumor but more
likely irritable bowel syndrome (large
bowel tumor is more often change from
normal to more frequent).
SYMPTOMS IN GI
PROBLEMS
Loss of Appetite/Loss of Weight
Basic questions you would ask in Loss of appetite/ Loss of Weight
• When did this happen, did it start
same time as other GI symptoms?
• Loss of appetite (anorexia) +
weight loss = Suspicious of
malignancy.
• Increase in appetite, may suggest
hypermetabolic state, e.g.
thyrotoxicosis
• When did it start?
• How much (in kg over weeks) if patient
not sure, ask about loose clothes?
• Why do you think lost weight-may say
on diet? - intentional or unintentional
• Are there other symptoms-may need
full review of systems, e.g. fever/thirst?
LOSS OF APPETITE LOSS OF WEIGHT
SIGNS IN GI PROBLEMS
(PHYSICAL EXAMINATION)
Dr.B.SELVARAJ MS;Mch;FICS;
Professor of Surgery
Melaka Manipal Medical college
Melaka 75150 Malaysia
SIGNS IN GI PROBLEMS
FACE:
Jaundice
Lemon yellow (uremia, CA
cecum,pernicious anemia)
Weight loss ( temporalis muscles, cheeks )-
cachexia
Dehydration
Distress (pain)
Pale (anemia/pain)
Flushed (temperature)
EYES:
Yellow sclera
Pale mucous membranes
Kayser-Fleischer rings (Wilson's disease)
MOUTH:
Angular stomatitis (B12 deficiency, Fe deficiency)
Pigmentation (Peutz-Jeghers syndrome)
Ulcers (Crohn's disease)
HANDS:
Finger nails leukonychia (low protein)
Koilonychia (Fe deficiency)
Clubbing (UC/Cirrhosis)
PALMS:
Pale creases (anemia)
Palmar erythema (liver failure)
Liver flap (liver failure)
ARMS:
Scratch marks ( obstructive jaundice)
SIGNS IN GI PROBLEMS
NECK:
Enlarged lymph nodes (supraclavicular-
CA stomach)
LEGS:
Superficial thrombophlebitis
(Pancreatic CA)
AXILLA:
Acanthosis Nigricans (Ca stomach)
Irish nodes ( Ca stomach)
CHEST:
Spider nevi (liver failure)
Gynecomastia (liver failure)
ABDOMEN: Inspection:
No movement with respiration (peritonitis)
Jaundiced
Distended ( obstruction, ascites)
Weight loss (malignancy)
Scars (previous surgery)
Fistula ( Crohn's)
Everted umbilicus (ascites)
Mass ( tumor, abscess)
Visible peristalsis (intestinal obstruction)
Pulsatile Swelling- Expansile/transmitted
Enlarged veins + caput medusa (liver disease)
Cullen's/Grey Turner's sign(pancreatitis)
Erythema ab igne (pain/hotwater bottle use)
Sister Joseph's nodule(transcelomic spread of tumor)
Cellulitis ( abscess-diverticulardisease/tumor)
SIGNS IN GI PROBLEMS
PALPATION:
Tenderness/guarding/rebound
(inflammation)
Rigidity- Perforative perotonitis
Mass (tumor)
ORGANOMEGALY:
Liver (primary CA/metastases)
Tender+ enlarged (hepatitis)
Small + hard (cirrhosis)
Spleen-enlarged
(portal hypertension)
ANORECTAL EXAM:
Fistula (Crohn's)
Fissure (Crohn's)
Abscess (IBD)
Anal cancer
Rectal prolapse
Prolapsed haemorrhoids
DRE:
Tumor/polyp felt
Blood on finger (tumor/lBD)
Pus/mucus (IBD)
Black motion (melena)
pale motion ( obstructive jaundice/
steatorrhea)
Symptoms & Signs in GIT problems

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Symptoms & Signs in GIT problems

  • 1. SYMPTOMS & SIGNS IN GI PROBLEMS (History & Physical) Dr.B.SELVARAJ MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical college Melaka 75150 Malaysia
  • 2. SYMPTOMS IN GI PROBLEMS (History Taking) Dr.B.SELVARAJ MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical college Melaka 75150 Malaysia
  • 3. SYMPTOMS IN GI PROBLEMS • Pain abdomen • Difficulty in swallowing- Dysphagia • Vomiting • Heartburn- Retrosternal pain- Pyrosis • Indigestion • Change in bowel habits-Constipation/Diarrhea • Loss of appetite/ Loss of weight
  • 4. SYMPTOMS IN GI PROBLEMS PAIN ABDOMENBasic questions you would ask in Abdominal pain • When did the pain start? • Where is it, show me? • Have you ever had it before? • Did it come on suddenly or gradually? • Does it go anywhere else? Show me. • How bad is it, worst you have ever had, severe, very severe, mild, moderate, just an ache (do not use x/10 unless you define 10)? • Is it the same all the time? • Have you had time completely free of pain since it started? • Is it constant or comes in waves? • Is it getting worse? • What makes it better, e.g. lying still/painkillers? • What makes it worse, e.g. moving about? • Have you got any other symptoms with it, give examples, e.g. vomiting/fever
  • 5. SYMPTOMS IN GI PROBLEMS Difficulty in Swallowing- Dysphagia Basic questions you would ask in Dysphagia • How long have you had the problem? • Describe what it is like? • Have you had it before? • Did it come on gradually or suddenly? • Is it becoming worse? • Do you have difficulty with solids and/ or liquids? • Which came first? • Does the food seem to stick. Show me where? • Have you been vomiting, what, etc. (see below)? • How is your appetite? • Have you lost weight? • Plus, all the other GI protocol questions • Plus, do you feel anything else wrong with you at present.
  • 6. SYMPTOMS IN GI PROBLEMS VOMITINGBasic questions you would ask in Vomiting • When did the vomiting start? • What do you vomit? • Is it food/water/bile/greeny stuff/acid/blood? • If food, is it food you have just eaten or old food? • If it is blood, how do you know? Amount, color, clots, coffee grounds. • How often do you vomit? • Do you feel sick (nauseated) all the time? • Does anything bring the vomiting on (worse)? • Does anything make it better? • Does it shoot out with great force (projectile)? • Any coughing or choking?
  • 7. SYMPTOMS IN GI PROBLEMS Heartburn- Retrosternal Pain- Pyrosis Basic questions you would ask in Retrosternal Pain • Describe it to me . • How long have you had it? • Have you had it before this episode? • Did it come on gradually or suddenly? • Is it becoming worse? • What makes it worse (e.g. lying down in bed, bending over, certain types of food and drink-spicy food/ alcohol/coffee)? • What makes it better ( sleeping, sitting up, avoiding certain drinks or food, medications)? • Do you get any acid reflux-acid or water coming into your mouth, describe this please (distinguish acid reflux and water-brash). • Do you have any difficulty swallowing? Describe. • Do you have any pain behind the chest bone? Describe. • Do you vomit? • Do you have indigestion? • Have you put on weight recently?
  • 8. SYMPTOMS IN GI PROBLEMS INDIGESTIONBasic questions you would ask in Indigestion • Do you have any indigestion, if says 'yes'? • Ask what do you mean by this, if says 'no; ask: do you have any discomfort or pain in your tummy after eating? • Where is the discomfort, show me (pointing sign of DU)? • When do you get it-before meals/ after meals? • Does it wake you at night (DU), what do you do about it, e.g. get up have some milk and a biscuit (DU)? • How often do you get it, e.g. every day? • Have you had it before? • Have you seen your GP about it or been investigated in hospital (e.g. endoscopy)? • What did they say was wrong with you? • What makes the indigestion worse/better? • Have you been vomiting any blood? • How is your appetite; have you lost weight? • Do you take any medications for it (define)? • Are you taking aspirin/NSAIDs/ steroids/ herbal medications?
  • 9. SYMPTOMS IN GI PROBLEMS Altered Bowel HabitsBasic questions you would ask in Altered Bowel Habits • Has your bowel habit changed recently? • If patient does not appear to understand-Explain. • Have you developed diarrhea or constipation recently (means different things to different people)? • Define their normal bowel habit. • Define what it has changed to, e.g. normal is x 1 per day now is x 3 per day. • If has diarrhea-define content, color, offensive, blood/floats (see set of questions below). • If has constipation-is it constipation or incomplete evacuation? or even tenesmus (see below set of questions)? • Have you passed any blood or slime? Define both. • Have you had any abdominal pain or weight loss? • On any drugs ( e.g. antibiotic)?
  • 10. SYMPTOMS IN GI PROBLEMS Altered Bowel HabitsBasic questions you would ask in Diarrhea • Frequency of defecation (>x3 = abnormal). • Recent or present for long time. • Solid/liquid/mixed. Bulky may be steatorrhea. • Color: Black (melena), red (blood), pale (steatorrhea,obstructive jaundice), silver (because of mixture of melena and fatty stool in tropical sprue, carcinoma (Ca) of ampulla of Vater). • Pus or mucus. • Smell-very offensive, may be infective/melena. • Floats/ difficult to flush away, may be steatorrhea. • Any other symptoms, e.g. vomiting. • Been abroad recently. • Anyone else in family with it (gastroenteritis). • NB: Some gastroenterologists divide by physiological cause into secretory, osmotic, exudative, malabsorption (not very useful in practice).
  • 11. SYMPTOMS IN GI PROBLEMS Altered Bowel Habits Basic questions you would ask in Constipation • What do you mean by constipation- infrequent bowel action or very hard motion or difficulty in evacuation? • Is this a new symptom or long standing? • If recent, define 'change': Normal bowel habit versus old bowel habit. • Any blood or mucus? • Incomplete emptying-have to go again-is a symptom of pelvic floor descent or rectal cancer- Tenesmus • Any incontinence-overflow or otherwise? • Painful almost continuous urge to defecate is tenesmus (rectal equivalent of urinary strangury) indicates inflammation or tumor involving anal sphincters. • Other GI symptoms, e.g. abdominal pain/distension. • On any drugs, e.g. codeine. • Alternating diarrhea + constipation, some say symptom of tumor but more likely irritable bowel syndrome (large bowel tumor is more often change from normal to more frequent).
  • 12. SYMPTOMS IN GI PROBLEMS Loss of Appetite/Loss of Weight Basic questions you would ask in Loss of appetite/ Loss of Weight • When did this happen, did it start same time as other GI symptoms? • Loss of appetite (anorexia) + weight loss = Suspicious of malignancy. • Increase in appetite, may suggest hypermetabolic state, e.g. thyrotoxicosis • When did it start? • How much (in kg over weeks) if patient not sure, ask about loose clothes? • Why do you think lost weight-may say on diet? - intentional or unintentional • Are there other symptoms-may need full review of systems, e.g. fever/thirst? LOSS OF APPETITE LOSS OF WEIGHT
  • 13. SIGNS IN GI PROBLEMS (PHYSICAL EXAMINATION) Dr.B.SELVARAJ MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical college Melaka 75150 Malaysia
  • 14. SIGNS IN GI PROBLEMS FACE: Jaundice Lemon yellow (uremia, CA cecum,pernicious anemia) Weight loss ( temporalis muscles, cheeks )- cachexia Dehydration Distress (pain) Pale (anemia/pain) Flushed (temperature) EYES: Yellow sclera Pale mucous membranes Kayser-Fleischer rings (Wilson's disease) MOUTH: Angular stomatitis (B12 deficiency, Fe deficiency) Pigmentation (Peutz-Jeghers syndrome) Ulcers (Crohn's disease) HANDS: Finger nails leukonychia (low protein) Koilonychia (Fe deficiency) Clubbing (UC/Cirrhosis) PALMS: Pale creases (anemia) Palmar erythema (liver failure) Liver flap (liver failure) ARMS: Scratch marks ( obstructive jaundice)
  • 15. SIGNS IN GI PROBLEMS NECK: Enlarged lymph nodes (supraclavicular- CA stomach) LEGS: Superficial thrombophlebitis (Pancreatic CA) AXILLA: Acanthosis Nigricans (Ca stomach) Irish nodes ( Ca stomach) CHEST: Spider nevi (liver failure) Gynecomastia (liver failure) ABDOMEN: Inspection: No movement with respiration (peritonitis) Jaundiced Distended ( obstruction, ascites) Weight loss (malignancy) Scars (previous surgery) Fistula ( Crohn's) Everted umbilicus (ascites) Mass ( tumor, abscess) Visible peristalsis (intestinal obstruction) Pulsatile Swelling- Expansile/transmitted Enlarged veins + caput medusa (liver disease) Cullen's/Grey Turner's sign(pancreatitis) Erythema ab igne (pain/hotwater bottle use) Sister Joseph's nodule(transcelomic spread of tumor) Cellulitis ( abscess-diverticulardisease/tumor)
  • 16. SIGNS IN GI PROBLEMS PALPATION: Tenderness/guarding/rebound (inflammation) Rigidity- Perforative perotonitis Mass (tumor) ORGANOMEGALY: Liver (primary CA/metastases) Tender+ enlarged (hepatitis) Small + hard (cirrhosis) Spleen-enlarged (portal hypertension) ANORECTAL EXAM: Fistula (Crohn's) Fissure (Crohn's) Abscess (IBD) Anal cancer Rectal prolapse Prolapsed haemorrhoids DRE: Tumor/polyp felt Blood on finger (tumor/lBD) Pus/mucus (IBD) Black motion (melena) pale motion ( obstructive jaundice/ steatorrhea)