Some of GI / Abdominal Symptomatology of Surgical Importance

TAKING HISTORY FROM A PATIENT WITH ABDOMINAL/GIT PROBLEM

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

  • Abdominal pain
  • Abdominal swelling
  • Related to esophagus and mouth
    • Halitosis
    • Salivation
    • Dysphagia
    • Heart burn
    • Reflux
    • Painful swallowing or odynophagia
  • Related to upper GIT
    • Dyspepsia or indigestion
    • Eructation
    • Flatulence
    • Hiccups
    • Vomiting
    • Retching
  • Related to lower GIT
    • Bowel habits
    • Constipation
    • Diarrhea
    • Dysentery
    • Worms in stool
  • Related to bleeding
    • Haematemesis
    • Rectal bleeding
    • Melena
  • Hepatobiliary
    • Jaundice
    • Itching
    • Encephalopathy
    • Bleeding tendency
    • Weight loss
  • Constitutional manifestations
    • Fever
    • Headache
    • Malaise
    • Sweating
    • Fatigue

Differential diagnosis of different abdominal presentations

Abdominal Pain

Principle causes of abdominal pain
  • Inflammation/infection
  • Perforation of a viscus
  • Obstruction of a viscus
  • Infarction/strangulation
  • Intraperitoneal/retroperitoneal haemorrhage
  • Injury
  • Extra-abdominal and medical causes
  • Then think anatomical
The common conditions that present with acute upper abdominal pain
  • Oesophagitis
  • Boerhaave’s syndrome
  • Acute gastritis
  • Perforated peptic ulcer
  • Acute cholecystitis
  • Gallstone and biliary colic
  • Acute pancreatitis
The common conditions that present with chronic upper abdominal pain
  • Chronic peptic ulceration
  • Carcinoma of the stomach
  • Chronic cholecystitis
  • Chronic pancreatitis
  • Liver metastases
  • Splenomegaly
The common conditions that present with acute central abdominal pain
  • Meckel’s diverticulitis
  • Acute gastroenteritis
  • Inflammatory bowel disease
  • Acute Crohn’s disease
  • Acute ulcerative colitis
  • Yersinis ileitis
  • Typhoid
  • Tuberculosis
  • Urinary tract infection
The common conditions that present with chronic central abdominal pain
  • Crohn’s disease
  • Tuberculosis
  • Radiation bowel damage
  • Tumors of the small bowel
  • Recurrent adhesive obstruction/malrotation
  • Ischemia of small bowel
  • Endometriosis
The common conditions that present with acute and chronic lower abdominal pain
  • Appendicitis
  • Crohn’s disease
  • Carcinoma of caecum and right colon
  • Diverticular disease
  • Carcinoma of left colon/rectum
  • Bladder outflow obstruction
  • Interstitial/irradiation cystitis
  • Pelvic inflammatory disease
The causes of generalised abdominal pain
  • Irritable bowel syndrome
  • Recurrent adhesive obstruction
  • Mesenteric ischemia
  • Carcinomatosis
  • Chronic constipation
  • Radiation damage
  • Retroperitoneal tumors
  • Endometriosis
  • Pelvi-ureteric junction obstruction
  • Lumbar spine pain
  • Retroperitoneal fibrosis
  • Psychosomatic
Infarction of viscus causing abdominal pain
Organ  Mechanism
Small and large bowel
  • Strangulation
  • Volvulus
  • Arterial thrombosis
  • Arterial embolism
  • Dissecting aneurysm
  • Venous thrombosis
Ovary Torsion pedicle
Omentum/appendix epiploica Strangulation
Stomach Volvulus
Spleen/kidney/liver Arterial occlusion
Extra-abdominal and medical conditions causing acute abdominal pain

Endocrine and metabolic disorders
Uremia
Diabetic crisis
Addisonian crisis
Acute intermittent porphyria
Acute hyperlipoproteinemia
Hereditary Mediterranean fever
Hematologic disorders
Sickle cell crisis
Acute leukemia
Other dyscrasias
Toxins and drugs
Lead and other heavy metal poisoning
Narcotic withdrawal
Black widow spider poisoning
Infections and inflammatory disorders
Tabes dorsalis
Herpes zoster
Acute rheumatic fever
Henoch-Schonlein purpura
Systemic lupus erythematosus
Polyarteritis nodosa
Referred pain
Thoracic region
Myocardial infarction
Acute pericarditis
Pneumonia
Pleurisy
Pulmonary embolus
Pneumothorax
Empyema
Hip and back

Abdominal pain caused by intra-abdominal or retroperitoneal haemorrhage
  • Ruptured abdominal aortic aneurysm
  • Ruptured spleen
  • Ruptured ectopic pregnancy
  • Ruptured ovarian cyst
  • Haemorrhage from a liver adenoma
  • Ruptured visceral aneurysms
    • Splenic
    • Hepatic
    • Mesenteric
  • Torn mesentery
  • Retroperitoneal haemorrhage
Causes of abdominal pain that are usually forgotten
  • Pancreatitis
  • Aneurysms (leaking or dissecting)
  • Mesenteric ischemia
  • Herpes zoster ‘shingles’
  • Prophyria
  • Diabetes
  • Tabes Dorsalis
  • Sickle-cell anaemia
  • Pneumonia

Abdominal Masses

CHIASMA

Hepatomegaly

Splenimegaly

Congestive
  • Right heart failure
  • Tricuspid regurgitation
  • Budd-Chiari syndrome
  • Portal hypertension
  • Hepatic vein obstruction
Heamatological
  • Lymphoma
  • Leukemia
  • Heamolytic anaemia
  • Sickle cell disease/thalasseamia
  • Lymphoma
  • leukemia
Infection
  • Viral (hepatitis – EBV – Cytomegalovirus)
  • Bacterial (TB – liver abscess)
  • Protozoal (malaria – amoebiasis – hydatid – schistosomiasis)
  • Acute (HIV – EBV – Cytomegalovirus – infective endocarditis)
  • Chronic (malaria – schistosomiasis – brucella – toxoplasmosis – leishmaniasis)
Amyloid
  • Sarcoidodsis
Storage disorder
  • Wilson’s disease
  • Haemochromatosis
  • Gaucher’s disease
Masses
  • Primary
  • Secondary
Autoimmune
  • Alcoholic (Fatty liver – cirrhosis)
  • Rheumatoid arthritis
  • Felty’s syndrome

Massive splenomegaly

  • Myelofibrosis
  • Chronic myeloid leukaemia
  • Malaria
  • Tropical splenomegaly
  • Kala-azar (visceral leishmaniasis)
Differential diagnosis of a renal mass
  • Hydronephrosis
  • Pyonephrosis
  • Polycystic kidney
  • Renal tumors (Hypernephroma – Wilm’s tumor – Big renal cyst)
The causes of abdominal distension
  • Fetus
  • Flatus
  • Faeces
  • Fat
  • Fluid
    • Free (ascites)
    • Encysted
      • Ovarian cysts
      • Hydronephrosis
      • Urinary bladder
      • Pancreatic pseudocysts
      • Mesenteric cysts
      • Hydatid cysts
  • Large solid tumor
    • Fibroid
    • Enlarged liver
    • Enlarged spleen
    • Polycystic kidneys
    • Retroperitoneal sarcomata
Causes of right iliac fossa mass

Think anatomical

  • Appendix mass
  • Appendix abscess
  • Tuberculosis
  • Carcinoma of caecum
  • Crohn’s disease ‘terminal ileitis’
  • Iliac lymphadenopathy
  • Iliac artery aneurysm
  • Psoas abscess
  • Chondrosarcoma or osteosarcoma of ilium
  • Tumor in an undescended testis
  • Actinomycosis
  • Ruptured Epigastric artery
  • Spigelian hernia
  • Kidney transplant
  • Ovarian cyst/tumor
  • Fibroid
  • Malignant change in an undescended testis
Causes of left iliac fossa mass

Think anatomical 

  • Diverticulitis
  • Carcinoma of colon
  • Carcinoma of caecum !
  • Crohn’s disease ‘terminal ileitis’
  • Iliac lymphadenopathy
  • Iliac artery aneurysm
  • Psoas abscess
  • Chondrosarcoma or osteosarcoma of ilium
  • Tumor in an undescended testis
  • Actinomycosis
  • Ruptured Epigastric artery
  • Spigelian hernia
  • Kidney transplant
  • Ovarian cyst/tumor
  • Fibroid
  • Malignant change in an undescended testis

Clinical sequelae of portal hypertension

  • Porto-systemic collaterals
Site Presentation
Lower part of oesophagus and fundus of stomach Oesophageal or gastric varices
  • Haematemesis
  • Melena
  • Fresh bleeding per rectum
Anterior abdominal wall Caput medusa Venous hum
Lower rectum and anal canal Anorectal varices
Retroperitoneum
  • Splenomegaly
  • Congestion of whole GIT (Anorexia – Dyspepsia – Indigestion – Malabsorption – Abdominal discomfort)
  • Ascites

Gastrointestinal bleeding

Causes of haematemesis and melena
  • Common causes
    • Oesophgeal varices
    • Acute gastric erosion
      • Aspirin
      • Steroids
      • Trauma
      • Burn
      • Phenyl-butazone
    • Chronic peptic ulcer (spontaneous, steroid)
    • Carcinoma of stomach
    • Purpura
    • Heamophelia
  • Anatomical approach
    • Oesophgeal causes
      • Oesophageal varices
      • Reflex oesophagitis
      • Mallory Weiss syndrome
      • Booerheaves syndrome
    • Gastric causes
      • Multiple gastric erosions
      • Acute haemorrhagic gastritis
      • Chronic gastric ulcer
      • Benign or malignant neoplasm of the stomach
    • Duodenal causes
      • Acute duodenal ulcer
      • Chronic duodenal ulcer
  • General causes
    • Blood diseases
    • Purpura
    • Haemophilia
    • Thrombocytopenia
    • Leukaemia
  • Rare causes
    • Fundal varices
    • Hiatus hernia
    • Dieulafoy’s lesion
    • Aortic aneurysm
    • Aorto-enteric fistula
    • Haemobilia
    • Watermelon stomach
Causes of bleeding per rectum
  • General causes
    • Purpura
    • Haemophilia
    • Thrombocytopenia
    • Leukaemia
  • Lesions of anal canal
    • Haemorrhoids
    • Anal fissure
  • Colorectal causes
    • Congenital
      • Familial poliposis coli
    • Inflammatory
      • Acute bacillary dysentery
      • Amoebic dysentery
      • Bilharzial colitis
      • Ulcerative colitis
    • Vascular
      • Ischemic colitis
    • Neoplastic
      • Malignant and benign neoplasms of colon and rectum
    • Diverticular disease of the colon
    • Angiomatous malformation of colon
  • Hemorrhoids is the commonest cause of bleeding per rectum
  • Causes of massive bleeding per rectum
    • Diverticula
    • UC
    • Ischemic colitis
    • Angiodysplasia
    • Massive upper GIT bleeding
    • In children 
      • Meckel’s diverticulum
Forms of bleeding per rectum
Blood mixed with stool
  • Proximal colonic
Blood on surface of stool
  • Distal colonic
Blood without stool
  • Bleeding in rectum
  • Sever bleeding from a proximal site
Blood on toilet paper
  • Anal fissure or ulcer
General rules for GIT bleeding
2-5 ml normal blood loss
10-50 ml FOB ‘foecal occult blood’ in screening of colorectal cancer
50-100 ml  Enough to produce melena
1000 ml From upper GIT produce haematochesia
1000 ml In a day produce melena for 3-5 days, melena poor indicator of recent bleeding
The character (color) of blood passed from GIT depend upon:

  • Time expense in GIT
  • Site
Lower GIT bleeding by definition originate below Treitz ligament at D-J junction
Upper GIT bleeding by definition originate above Treitz ligament at D-J junction
Melena is bleeding above ilio-ceacal valve (digested blood)
So presence of melena indicate

  • Bleeding >100 ml
  • presence of melena for 3-5 days indicate
  • bleeding of 1000 ml
The causes of a discharge from the umbilicus
  • Congenital
  • Intestinal fistula
  • Patent uracus
  • Umbilical adenoma
  • Acquired
  • Umbilical granuloma
  • Dermatitis (intertrigo)
  • Ompholith (umbilical concretion)
  • Fistula (intestinal)
  • Secondary carcinoma
  • Endometriosis
Causes of portal hypertension
  • Increased resistance to flow
  • Prehepatic (portal vein obstruction)
    • Congenital atresia or stenosis
    • Thrombosis of portal vein
    • Thrombosis of splenic vein
    • Extrinsic compression (for example, tumours)
  • Hepatic
    • Cirrhosis
    • Acute alcoholic liver disease
    • Congenital hepatic fibrosis
    • Idiopathic portal hypertension (hepatoportal sclerosis)
    • Schistosomiasis
  • Posthepatic
    • Budd­Chiari syndrome
    • Constrictive pericarditis
  • Increased portal blood flow
    • Arterial­portal venous fistula
    • Increased splenic flow

Jaundice

Jaundice

Hemolytic Hepatocellular Obstructive
Cause Destruction of RBCs Liver dysfunction Outflow obstruction
Color Lemon yellow Orange yellow Olive green
Bilirubin Indirect Direct& idirect Direct
Associations Evidence of hemolysis Picture of LCF PruritusOther evidence of obstruction
Urine Darken on standing Dark Frothy dark
Stools Dark Pale Clay colored
Differences between hepatocellular jaundice and uncomplicated obstructive jaundice in LFTs
Test Normal value

Hepatocellular jaundice

Uncomplicated obstructive jaundice

Bilirubin

Direct

0.1-0.3 mg/dl + +
indirect 0.2-0.7 mg/dl
Urine bilirubin None + +
Serum albumin 3.5-5.5 g/dl Unchanged
ALP 30-115 units/l + +++
PT 1.0-1.4
  • Prolonged if sever damage
  • No response to parentral vitamin k
  • Prolonged if sever obstruction
  • Responed to parentral vitamin k
ALT 5-35 unit/l
  • +++
  • Hepatocellular damage
  • Viral hepatitis
+
AST 5-40 unit/l
Differences between calcular and malignant obstructive jaundice

Calcular

Malignant

Peak age incidence Middle age Elderly
Gender More in females More in males
Duration of jaundice May be long Short
Course if jaundice Intermittent Progressive
Depth of jaundice Moderate May be very deep
Abdominal pain Colicky

More in right hypochonderium

May be absent

If present it is dull aching

And referred to back

Anorexia & loss of weight Absent Marked
Fever May be present Usually absent
Gall bladder palpation Usually impalpable Commonly palpable
Ultrasound Usually fibrosed gall bladder with stones Marked distended thin walled gall bladder
CT scan Gall stones Head neoplasm is usually seen
ERCP Stone in CBD Irregular filling or

Failure of cannulation of CBD

Causes of postoperative jaundice
  • Prehepatic jaundice (bilirubin overload)
    • Hemolysis (drugs, transfusions, sickle cell crisis)
    • Reabsorption of hematomas
  • Hepatocellular insufficiency
    • Viral hepatitis
    • Drug-induced (anesthesia, others)
    • Ischemia (shock, hypoxia, low-output states)
    • Sepsis
    • Liver resection (loss of parenchyma)
    • Others (total parenteral nutrition, malnutrition)
  • Posthepatic obstruction (to bile flow)
    • Retained stones
    • Injury to ducts
    • Tumor (unrecognized or untreated)
    • Cholecystitis
    • Pancreatitis
    • Occlusion of biliary stents

Dysphagia

  • Causes in the mouth
    • Stomatitis
    • Glossitis
    • Neoplasm of the tongue and cheek
  • Causes in the pharynx
    • Pharyngitis
    • Retropharyngeal abscess
    • Plummer Vinson syndrome
    • Pharyngeal diverticulum
    • Post-cricoid carcinoma
    • Lusoria (game of nature)
    • Globus hystericus
    • Neuromuscular
    • DM
    • Poliomyelitis
    • Myopathy
    • CVA
    • Pulpar palsy
  • Causes in the oesophagus
    • Mechanical
      • In the lumen
        • Foreign body
      • In the wall
        • Congenital
          • Atresia
        • Traumatic
          • Corrosive
          • Post-operative stricture
        • Inflammatory
          • Reflux oesophagitis
        • Neoplastic
          • Carcinoma
    • Compression from outside
      • Malignant thyroid
      • Malignant lymph nodes
      • Aortic aneurysm
      • Mediastinal tumors
  • Neuromuscular
    • Achalasia of the cardia
    • Paralysis of glossopharyngeal or vagus nerve
    • Tetanus
    • Myasthenia gravis
    • Hysteria

Intestinal Obstruction

The Conditions likely to cause acute mechanical intestinal obstruction
  • In the lumen
    • Faecal impaction
    • Gall stone ileus
    • Parasitic infestation
    • Mecomium
  • In the wall
    • Congenital atresia
    • Tumors
    • Crohn’s disease
    • Chronic diverticulitis
    • Mesenteric vascular occlusion
  • Outside the wall
    • Adhesions commonly Postoperative
    • Strangulated hernia
    • Volvulus
    • Intussusceptions
    • Malignant tumors
Age and the common causes of alimentary tract obstruction
Neonates
  • Atresia (duodenal, ileum)
  • Meconium obstruction
  • Volvolus neonatorum
  • Anorectal malformations
  • Hirschsprung’s disease
3 weeks
  • Congenital hypertrophic pyloric stenosis
6-9 monthes
  • Intussusception
  • Hirschsprung’s disease
  • Strangulated hernia
Teenage
  • Inflammatory masses (appendicitis)
  • Intussusception of Meckel’s diverticulum or polyp
Young adult
  • Hernia
  • Adhesions
Adult
  • Hernia
  • Adhesions
  • Inflammation
  • Appendicitis
  • Crohn’s disease
  • Carcinoma
Elderly
  • Carcinoma
  • Inflammation
  • Diverticulitis
  • Sigmoid volvulus
  • Strangulated hernia