GIT Symptomatology

Lecture On GIT Symptomatology Dr Monem Alshok
ألمرحلة ألثالثة
CLINICAL APPROACH TO GASTROINTESTINAL SYMPTOMS AND SIGN
Dry Mouth , Water Brush , Globus ,Halitosis , Heart Burn , Acidity

Dysphagia :
Difficulty in swallowing ( Deglutition )
Swallowing reflex needs Oral phase , Pharyngeal phase and Oesophageal phase .
Intact Oropharynx & intact NS ( 9th. & 10th. Nerve )
Questionnaires for Dysphagia :
*Site
*Solid or Liquid
*Odenophagia
*Progressive or Intermittent
*Any Regurgitation
*Associated symptoms
*Any nasal or pulmonary symptoms
* Neurogenic dysphagia is usually oropharyngeal and associated with spluttering & speech defect .


Dyspepsia and indigestion
Dyspepsia is the term used by healthcare workers to describe upper abdominal symptoms, e.g. nausea, heartburn, acidity, pain or discomfort, wind, fullness or belching. Patients seldom use the term dyspepsia ; they are more likely to refer to indigestion to describe any symptom that is food related. Indigestion is common; 80% of the population will have had indigestion at some time
Alarm features suggestive of serious disease are:
• dysphagia
• weight loss
• protracted vomiting
• anorexia
• haematemesis or melaena
Nausea and vomiting
There are three phases:
• nausea - a feeling of wanting to vomit, often associated with autonomic effects including hypersalivation, pallor and sweating
• retching - a strong involuntary effort to vomit
• vomiting - the expulsion of gastric contents through the mouth
The vomiting centres are located in the lateral reticular formation of the medulla and are stimulated by the chemoreceptor trigger zones (CTZs) in the floor of the fourth ventricle, and also by vagal afferents from the gut. These zones are directly stimulated by drugs, motion sickness and metabolic causes. Many gastrointestinal conditions are associated with vomiting , but nausea and vomiting without pain are frequently non-gastrointestinal in origin. Haematemesis is vomiting blood or coffee-grounds from the stomach .

In a patient with hematemesis ask for ?
1. Fresh blood ( Oesophageal varices )
2. Coffee – ground ( altered blood in the stomach )
3.Clots ( Severity )
4. Drugs ( Aspirin )
5. History of preceedind dyspepsia , Hx, of Retching or repeated vomiting
6. Malena
Large volumes of vomit suggest intestinal obstruction; faeculent vomit suggests low intestinal obstruction or the presence of a gastrocolic fistula, while projectile vomiting is due to gastric-outflow obstruction

Chronic nausea ± vomiting with no other abdominal symptoms is usually due to a psychological cause
Early-morning vomiting is seen in pregnancy, alcohol dependence and some metabolic disorders (e.g. uraemia )
In a patient who presents with Vomiting Ask for ?
* Drug
* Nausea ornot
* Dyspepsia
* Vertigo or dizziness
* Relation to meal & its duration following meal
* Blood
* Taste of Vomits , Odors , Color
* Projectile or not , Morning

Flatulence
This is the term used to describe excessive wind. It includes belching, abdominal distension, wind or the passage of flatus per rectum. Swallowing air (aerophagia) is. swallowed air is passed into the intestine where most of it is absorbed. Intestinal bacterial breakdown of food also produces a small amount of gas. Flatus consists of nitrogen, carbon dioxide, hydrogen and methane. Flatus is normally passed 13-20 times per day.

Diarrhoea and constipation

These are common complaints which are not usually due to serious disease
Diarrhoea is a common clinical problem and there is no uniformly accepted definition of diarrhoea. Organic causes (stool weights > 250 g per day) have to be distinguished from functional causes , and is the first step in the assessment of the history. Sudden onset of bowel frequency associated with crampy abdominal pains, and a fever will point to an infective cause; bowel frequency with loose blood-stained stools to an inflammatory basis; and the passage of pale offensive stools that float, often accompanied by loss of appetite and weight loss, to steatorrhoea. Nocturnal bowel frequency and urgency usually point to an organic cause. Passage of frequent small-volume stools (often formed) points to a functional cause
Mechanisms:
Osmotic diarrhea
Secretory diarrhea
Inflammatory diarrhoea (mucosal destruction )
Abnormal motility

Types of Diarrhea :
Acute diarrhea ( Less than 2 weeks )
Chronic diarrhea( more than 4 weeks )

Constipation is defined as infrequent passage of stool (less than 2 motions per week ) associated with straining more than 25% of time ,with passage of difficult hard stool & feeling of incomplete evacuation .
For patients with constipation ask for ?
1. Drugs history .
2. Straining & passage of pelletty – like stool.
3. Duration & onset
4. Any local anal symptoms or GIT conditions , Bleeding PR.
5. Bowel Habit
Constipation of TWO types :
Slow Transit ( rarely experiencedesire or call to defecate )
Obstructive .
What are the important causes of constipation ?
*Dietary cause.
*Drugs ( Verapamil , Opiates and Anticholinergics )
*Immobility
*IBS
*Endocrine
*Metabolic
What are the characteristic stool :
GIT conditions Stool Characteristic
Upper GIT Bleeding Black Tarry ( Malaena )
Ca. Ampulla of Vater Silvery Pale
IBD Bloody with excess Mucus
Intestinal Intususception Red – Current Jelly
IBS Pellets - like
Iron , Bismuth Black Solid
Malabsorption
Chronic Pancreatitis Pal Bulky Offensive or Steatorrhea

Abdominal pain:( 1.Site & Onset , 2. Radiation , 3. Character , 4. Severity , 5. Duration , 6. Frequency & Periodicity ,7. Special time of its occurrence 8. Aggrevating Factors , 9. Relieving factors and 10. Associated Phenomenon.
Pain is stimulated mainly by the stretching of smooth muscle or organ capsules. Severe acute abdominal pain can be due to a large number of gastrointestinal conditions, and normally presents as an emergency . An acute abdomen can occasionally be due to referred pain from the chest, as in pneumonia, or to metabolic causes, such as diabetic ketoacidosis
In patients with abdominal pain the following should be ascertained:
• the site, intensity, character, duration and frequency of the pain
• the aggravating and relieving factors
• associated symptoms, including non-gastrointestinal symptoms
Upper abdominal pain
Epigastric pain is very common; it is often a dull ache, but sometimes sharp and severe. Its relationship to food intake should be ascertained. It is a common feature of peptic ulcer disease, but also occurs in functional dyspepsia. In biliary tract disease, the pain is often epigastric

Right hypochondrial pain is usually from the gall bladder or biliary tract. Hepatic congestion (e.g. in hepatitis) and sometimes peptic ulcer can present with pain in the right hypochondrium. Chronic, often persistent, pain in the right hypochondrium is a frequent symptom in healthy females suffering from functional bowel disorders. This chronic pain is not due to gall bladder disease


Lower abdominal pain
Acute pain in the left iliac fossa is usually colonic in origin (e.g. acute diverticulitis). In thr RIF suggestive of acute appendicitis Chronic pain is most commonly associated with functional bowel disorders.
In females, lower abdominal pain occurs in a number of gynaecological disorders and the differentiation from GI disease is often difficult
Proctalgia is a severe pain deep in the rectum that comes on suddenly but lasts only for a short time. It is not due to organic disease.

Weight loss
This is due to anorexia (loss of appetite) and is a frequent accompaniment of all gastrointestinal disease. Anorexia is also common in systemic disease and may be seen in psychiatric disorders, particularly anorexia nervosa
Anorexia often accompanies carcinoma but it is a late symptom and not of diagnostic help. Weight loss with a normal or increased dietary intake occurs with hyperthyroidism. Malabsorption is never so severe as to cause weight loss without anorexia. Weight loss should be assessed objectively as patients often think they have lost weight.

Altered Bowel Habits : may be the first symptom of serious underlying diseases .

Hiccup ( Hiccough):
Is a complex reflex pattern , characterized by sudden contraction of diaphragm , inspiratory muscles , then terminated by an abrupt closure of glottis , resulting in characteristic hiccup sound . Causes ( Uremia , CNS diseases , Respiratory disorders in which there is irritation of vagus or phrenic nerve , and Psychogenic causes )

JAUNDICE

Jaundice (icterus) is detectable clinically when the serum bilirubin is greater than 50 ?mol/L (3 mg/dL). The usual division of jaundice into prehepatic, hepatocellular and obstructive (cholestatic) is an oversimplification as in hepatocellular jaundice there is invariably cholestasis and the clinical problem is whether the cholestasis is intrahepatic or extrahepatic. Jaundice will therefore be considered under the following headings:
• haemolytic jaundice - increased bilirubin load for the liver cells
• congenital hyperbilirubinaemias - defects in conjugation
• cholestatic jaundice, including hepatocellular (parenchymal) liver disease and large duct obstruction
• Hepatitic
Haemolytic jaundice
The increased breakdown of red cells leads to an increase in production of bilirubin. The resulting jaundice is usually mild (serum bilirubin of 68-102 ?mol/L or 4-6 mg/dL) as normal liver function can easily handle the increased bilirubin derived from excess haemolysis. Unconjugated bilirubin is not water-soluble and therefore will not pass into the urine; hence the term acholuric jaundice Urinary urobilinogen is increased. Causes of haemolytic jaundice are those of haemolytic anaemia .The clinical features depend on the cause; anaemia, jaundice, splenomegaly, gallstones and leg ulcers may be seen. Investigations show features of haemolysis The level of unconjugated bilirubin is raised but the serum ALP, transferases and albumin are normal. Serum haptoglobulins are low. The differential diagnosis is from other forms of jaundice
Congenital hyperbilirubinaemias
Unconjugated (Gilbert s syndrome )
Conjugated ( Dubin-Johnson )
Cholestatic jaundice (acquired) This can be divided into extrahepatic and intrahepatic cholestasis. The causes are
• Extrahepatic cholestasis is due to large duct obstruction of bile flow at any point in the biliary tract distal to the bile canaliculi.
Intrahepatic cholestasis occurs owing to failure of bile secretion. A number of cellular mechanisms in cholestasis have been described in animal models, including inhibition of the Na+-K+-ATPase in the basolateral membranes, decreased fluidity of the sinusoidal plasma membrane, disruption of the microfilaments responsible for canalicular tone, and damage to the tight junctions. In addition, inflammatory change in ductular cells interferes with bile flow. Clinically in both types there is jaundice with pale stools and dark urine, and the serum bilirubin is conjugated. However, intrahepatic and extrahepatic cholestatic jaundice must be differentiated as their clinical management is entirely different


Differential diagnosis of jaundice:
A careful history may give a clue to the diagnosis. Certain causes of jaundice are more likely in particular categories of people. For example, a young person is more likely to have hepatitis, so questions should be asked about drug and alcohol use, and sexual behaviour. An elderly person with gross weight loss is more likely to have a carcinoma. All patients may complain of malaise. Abdominal pain occurs in patients with biliary obstruction by gallstones and, sometimes with an enlarged liver there is pain resulting from distension of the capsule.
Questions should be appropriate to the particular situation, and the following aspects of the history should be covered.
• Country of origin. The incidence of hepatitis B virus (HBV) infection is increased in many parts of the world
• Duration of illness. A history of jaundice with prolonged weight loss in an older patient suggests malignancy. A short history, particularly with a prodromal illness of malaise, suggests a hepatitis.
• Recent outbreak of jaundice. An outbreak in the community suggests hepatitis A virus (HAV).
• Recent consumption of shellfish. This suggests HAV infection.
• Intravenous drug abuse, or recent injections or tattoos. These all increase the chance of HBV and hepatitis C virus (HCV) infection.
• Male homosexuality. This increases the chance of HBV infection.
• Female prostitution. This increases the chance of HBV infection.
• Blood transfusion or infusion of pooled blood products. Increased risk of HBV and HCV. In developed countries all donors are screened for HBV and HCV.
• Alcohol consumption. A careful history of drinking habits should be taken, although many patients often understate the actual amount they drink.
• Drugs taken (particularly in the previous 2-3 months). Many drugs cause jaundice.
• Travel. Certain areas have an increased risk of HAV infection as well as hepatitis E (HEV) infection (this has a high mortality in pregnancy).
• A recent anaesthetic. Halothane and occasionally enflurane, isoflurane, for example, may cause jaundice, particularly in those already sensitive to halogenated anaesthetics. The risk with desflurane appears remote.
• Family history. Patients with, for example, Gilbert s disease may have family members who get recurrent jaundice.
• Recent surgery on the biliary tract or for carcinoma.
• Environment. People engaged in recreational activities in rural areas, as well as farm and sewage workers, are at risk for leptospirosis.
• Fevers or rigors. These are suggestive of cholangitis or possibly a liver abscess

Questionnaires ? 10 letters
A Appetite, Abdominal pain, Asian , Anesthesia – operation. , Acute Onset
B Blood , Bleeding
C Contacts, Conscious , Changes in weight , sleep , behavior ,Country origin
D Drugs , Duration of jaundice, Diet ( Mushroom ) , Dentist
E Ethanol ( Alcohol) Enironment & Sanitation, Encephalopathy
F Family history,
G Gall stone Triads
H Hemolytic , Homosexuality , Halothane , Hallucination
I Injection,( Tatto Needles ) , Itching , Immunity
J Jop

Ascites :
Fluid accumulation in peritoneal cavity
Types :
1- Transudative ( Liver Cirrhosis, NS , HF , Hypoproteinemia )
2- Exudative ( TB , Malignancy , Pancreatitis , Lymphatic obstruction )