SIGNS AND SYMPTOMS OF

GIT DISORDERS

Vidi Orba Busro

DEPARTEMENT OF INTERNAL MEDICINE

DIVISION OF GASTROENTERO-HEPATOLOGY
FK UNSRI
DEFINITION

Symptom : Subjective data of patients

complaints
Symptom the most important thing in
directing or guiding a diagnostic (60%)
Sign : Objective data of physical findings
References: Adams Physical Diagnosis
Harisson Signs &Symptoms
Diagnostic Procedure

SOAP
S Subjective (identity, symptoms,
clinical history, genetics)
O Objective (signs, laboratory,
radiologic, etc)
A Assesment (diagnostic & DD)
P Planning (treatment, supporting
examination)
Basic of Symptoms and Signs

Anatomical
- topography
- vascularization and innervation
Physiological
- organ function
- metabolism
Celiac Axis Anatomy
3 major branches
1. (L) gastric A
2. Common Hepatic A
- Gastroduodenal
- gastroepiploic
- S pancreaticoduodenal
3. Splenic A
- Pancreatic A
- (L) gastroepiploic A
Superior Mesenteric Artery Anatomy

4 major vessels:
1. Inferior
pancreaticoduodenal
2. Middle colic A
3. colic A
4. Ileocolic A
Inferior Mesenteric Artery Anatomy
TOPOGRAPHY
Abdominal regions RHC EPI LHC

nine regions system RL LL

UMB
or
RI LI
four regions system SP
Organ Function

Esophagus
- swallowing
Gaster & duodenum
- digestive and absorbtion
Liver
- anabolism and catabolism
- detoxification
- erythropoesis extramedular
- bile secretion
 Pancreas
- hormone secretion
- enzyme secretion
Colon
- reabsorbtion
- faecal formation
Rectal
- faecal reservoar
Symptoms

1. Abdominal Pain
- the most common symptom
- location, type, continuous or intermitten,
spread, referred
- location depend on topography
- due to : GIT ,TUG, Gyn, MSC, & CV
- intermittent pain related to luminar organ
(colic)
- referred pain depend on innervasion
Clinical Diagnosis

Location of pain by organ

RUQ

Gallbladder
Epigastrium

Stomach
Pancreas
Mid abdomen

Small intestine
Lower abdomen

Colon, GYN pathology

Clinical Diagnosis
Types of abdominal pain

- epigastric pain gastroduodenitis,

pancreatitis, inferior MCI, left liver
abcess, hepatic disorders, lymphoma,
aneurisma aorta
- Biliary colic pain from the right
hypochondrial spread to right back
shoulder gallstone & CBD stone
- Renal colic pain from back CVA
spread to right iliac region
obstructive uropathy
- Right hypochondrial pain hepatic
disorders, gall disorders, pleuritis,
TUG disorders, and colon disorders
- Left hypochondrial pain gastritis,
pseudocyst pancreas, colon disorders
TUG disorders, pleuritis, and spleen
disorders
- Umbilical pain gastritis, enteritis,
colitis, aneurisma aorta, thrombosis of
mesenteric artery
- Right & left lumbal pain colon
disorders , TUG disorders, psoas abcess
- Right iliac pain appendicitis,
colon disorders, psoas abcess, PID,
ovary cyst, ileitis term, TUG dis.
- Left iliac pain colon disorders,
psoas abcess, PID, ovary cyst, TUG
disorders
- Suprapubic pain cystitis & bladder
stone, gynaecologic disorders, prostat
disorders, colo-rectal disorders
- Whole abdomen pain peritonitis,
muscle pain, gastroenteritis, colitis
2. Abdominal Distention

Due to: gas, fluid, mass, organomegali

With or without pain ?
Acute, recurrent, or chronic ?
Bowel or micturia alteration ?
Organ involved: GIT, TUG, heart
3. Dysphagia

Difficulty swallowing
Due to pain, obstruction, abnormal peristaltic,
or impaired reflex (nerve)
Organ involved esophagus or oropharynx
Most common case: stricture esophagus,
malignancy, GERD, multiple sclerosis
4. Odinophagia

Pain of swallowing
Organ involved esophagus
Due to inflammation process
5. Heartburn

Burn sensation on the front chest

Due to reflux esofagitis
DD/ angina pectoris, intercostal neuralgia,
pulmonary problem, psychosomatic
Confounding factor: asthma, dyspepsia, no
cardiovascular risk factor, obesity
6. Hiccup or Singultus

Involuntary spasmodic contraction of the

diaphragm followed by sudden closure of
glottis
Due to increase of intracranial pressure,
abdominal distention, gastric dilatation or
inflammation, and renal failure, decrease
serum levels of carbondioxide
7. Vomitus & Regurgitation

Reflux of gastric contents

The difference with or without contraction
Involved vagal mechanism
Non specific all of GIT disorders
8. Bloating

Full sensation of stomach

Due to inflammation, gastric emptying
disorders, gastric mass, Increase of gastric
pressure, increase of gas production, full or
partial obstruction
9. Hematemesis

Bleeding of upper GIT (ligamentum Treitz)

Due to variceal rupture, ulcer, erotion, mass
Organ involved esophagus, stomach, &
duodenum
Life threatening symptom
Common cause: peptic ulcer, gastritis &
erosion, varices
10. Melena

Black bloody stool from upper GIT

Black color is due to oxidation of Hb
Bleeding above ligament of Treitz
Caused and organ involved similar to
hematemesis
Life threatening symptom
Etiology

Esophageal causes
- esophageal varices

- esophagitis

- esophageal cancer

- esophageal ulcer

- Mallory-Weiss tear
Gastric causes
- gastric ulcer

- gastric cancer

- gastritis

- gastric varices

- Dieulafoys lesion
Duodenal causes
- Duodenal ulcer

- Vascular malformation in including aorto-

enteric fistulae
- Hematobilia, bleeding from the biliary tree

- Hemosuccus pancreaticus, or bleeding from

the pancreatic duct
- Severe superior mesenteric artery
syndrome
11. Diarrhea

Watery stool more than 3 x/day

Acute or chronic ? ( 2 weeks )
Due to reabsorbtion impairment (osmotic,
toxin,etc) or hyperperistaltic (hyperthyroid)
Organ involved Intestinal and colorectal
 Passage of abnormally liquid or unformed stools
at an increased frequency
Stool weight >200gr/day
Consistency of the stools is more important
than the number of stools
Frequent passing of formed stools is NOT
diarrhea
 Acute, persistent, chronic diarrhea

Acute diarrhea
- < 2 weeks duration
- > 90% are caused by infectious agents
- Often accompanied by vomiting, fever, abdominal pain
Persistent diarrhea : 2-4 weeks duration
Chronic diarrhea
- > 4 weeks duration
- needs further evaluation to exclude serious underlying
pathology
- usually non-infectious in origin
12. Constipation

No defecation >3 days

Due to obstruction, hypoperistaltic,
inflammation, medication
Organ involved Colorectal
 Constipation a perception of abnormal bowel
movements include straining,hard
stool,decreased frequency,and a feeling of
incomplete evacuation.
The frequency of normal bowel movements is
broad ranging from 3 - 12/week.
The function of colon are storage and
conversion of liquid chyme to solid fecal bulk
and the timely elimination of fecal contents.
The colon divided into 3 functional regions :
1.Proximal colon,from cecum to the hepatic flexura,
fecal chyme is churned and mixed by rhythymic
segmental and retrograde contractions that retard
fecal passage and permit fluid resorption.
2.Distal colon, transverse colon to the rectosigmoid
junction,orthograde rhythmic contractions occur that
gradually move the more solid contents toward the
rectum, fluid resorption.
3.Rectum as a storage area until elimination is
convenient.
13. Hematoschezia

Fresh red bloody stool

Due to lower GIT
Haemorhoid is the most common cause of
hematoschezia
Acute, recurrent, or chronic ?
Bowel habit alteration ?
 Lower GI Bleeding bleeding from below the
ligament of treitz.
Hematochesia bright red blood passed per
rectum,usually suggests a left colon source of
bleeding, although it may occur with brisk upper
GI or small bowel bleeding and rapid transit of
blood.
Maroon stools maroon colored blood mixed
with melena and usually indicative of a lower GI
(right colon,small bowel bleeding with rapid
transit)
Signs

From physical findings

Most common in hepatobilliary disorders
General : vital sign
Specific : inspection, palpation, percusion,
and auscultation
Gentle
Right side of patients
1. Mental Change

Most common in end stage of cirrhosis

or severe hepatic disorders
Called as encephalopathy hepatic
Due to false neurotransmitter
(aromatic amino acids, ammonia)
Sometimes accompanied by flapping
tremor
2. Icteric or Jaundice

A yellow discoloration of the skin, mucous

membranes, or sclera of the eyes
Signs of excessive levels of conjugated or
unconjugated bilirubin in the blood
Type : Prehepatic, Hepatic, and Posthepatic
Commonly accompanied by pruritus
because bile pigment damage sensory
nerve (hepatic or posthepatic jaundice)
Icteric
JAUNDICE
 Tea dark colored urine, clay colored stools
always accompany obstructive or posthepatic
jaundice
Prehepatic jaundice hemolysis
Hepatic jaundice hepatic disorders,
congestive liver (heart), systemic inflammation
(sepsis, lupus), malignancy, and drugs
Posthepatic jaundice CBD stone,
malignancy of billiary system, lymphoma
3. Gynecomastia

Occuring only in males

Increased breast size due to excessive
mammary gland development
Most common in cirrhosis
Failure to inactivate circulating estrogen
4. Spider Nevi/Angioma

A fiery red vascular lession with an

elevated central body and a surrounding
flush
Most common in face, neck, and chest
Related with cirrhosis and
hyperestrogenemia (pregnancy)
5. Palmar Erythema

Local vasodilatation along palmar side

Most common in cirrhosis
Mechanism is unknown
6. Ascites

Accumulation of fluid in abdominal cavity

Due to decrease of osmotic pressure
(hypoalbumin) or increase of hydro-static
pressure (portal hypertension)
Signs shifting dullness, undulation
Nonspecific sign
Most common in cirrhosis, gynaecologic
disease, severe diseases, peritoneal
tuberculous, renal and heart problem
Etiology
Pathogenesis
Ascites

ascites accumulation of fluid in the abdominal cavity

7. Ileus

Accumulation of gas in abdominal cavity

Hypersonor percusion
Bowel sound ? Metalic sound ?
Pain ? Flatus ? Bowel Habit ?
Due to electrolyte imbalance, drug,
inflammation, total or partial obstructive
 Enteric Nervous System Controls
GI Electrical Rhythm
-30
Stomach mV
(3/min) -70
-22
Small
mV
intestine
-62
(8-12/min)
-41
Colon mV
(3-6/min)
-81
30 sec
Cause of mechanical obstruction

1.Abnormal tissue growth

2.Adhesions or scar tissue that form after
surgery
3.Foreign bodies
4.Gallstones
5.Hernias
6.Impacted feces
7.Intussusception/ volvulus
8.Tumor blocking the intestines
8. Pain palpation

Depend on topographic
Types: Murphys sign, Ludwigs sign,
CVA percussion pain, epigastric pain, Mc
Burtneys pain, defans muscular,
suprapubic pain
Adynamic ileus (~ paralytic)

Dilated small intestine (in the absence of

mechanical onstrustion)
Colonic gas still + : distinguishing from a
mechanical S B obstruction
Et/ : K , sepsis, peritonitis, blunt trauma,
infiltration of mesenterium by tumor
Small bowel obstruction
Often difficult to diagnose on the basis of abdominal
plain films
Factors : duration, frequency of emesis, use of NG
suction, bowel sounds?
DD/ : mechanical obstruction with hyperperistaltic from
an adynamic ileus
Complete obstruction : accumulation of swallowed air
and intestinal secretions causes proximal dilatations of
bowel
BNO :
Dilatation SB loops (>3cm)
Air fluid level often present (DD/ adynamic ileus)
Stepladder configuration
String of pearls sign
Colonic obstruction
Etiology: > 50% AdenoCa colon (sigmoid >)
BNO :
Dilated, gas filled loops of colon proximal
to the site of obstruction
Absence of gas in the distal colon and
rectum
Can mimic those of SB obstruction if
ileocaecal valve is incompetent right
lateral decubitus view to facilitate
passage of gas distally into the
descending colon/recto-sigmoid
9. Hepatomegaly

Hepatic enlargement more than

normal (how the border?)
Confirmed by palpation, percussion,
and sonographic
Due to systemic or hepatic problems
Important things size, consistency,
and pain
Liver enlargement, portal hypertension
 LIVER SPAN

MCL

PERCUSSION

NL < 12-13 CM
2-3 CM DURING
PALPATION INSPIRATION AND
PERCUSSION EXPIRATION

SCRATCH TEST COPD

LIVER SPAN MAY VARY BETWEEN

OBSERVERS DEPENDING UPON
WHERE THE MCL IS DETERMINED

JAMA 1994;271:1859-1865
 PALPATION

FLEX KNEES AND HIPS IF POSSIBLE

BEGIN LOW ON ABDOMINAL WALL AND MOVE HAND CEPHALAD, HAVE
PATIENT TAKE A DEEP BREATH
NOTE CONSISTENCY (NODULES, SMOOTH) AND CONTOUR IF THE
LIVER EDGE IS FELT
NOTE IF THERE IS ANY PAIN WITH PALPATION
AUSCULTATE
MOSBYS GUIDE TO THE PHYSICAL EXAMINATION, 3RD ED. 1995
10. Splenomegaly

Enlargement of spleen more than normal

(how the border?)
Due to infection, trauma, portal
hypertension, neoplastic, hematologic
disorders
Confirmed by palpation and sonograph
11. Mass palpation

Depend on topographic (similar to

abdominal pain)
Important things size, consistency,
mobility, and pain
Confirmed by sonograph, radiograph,
and endoscopy
12. Flapping Tremor

Pathognomonic sign of encephalopathy

hepatic
Tremor of wrist joint after full extension
13. Pitting Edema

Accumulation of fluid in subcutis especially

in plantar pedis
Due to hepatic, renal, heart, malnutrition,
blood vessel, and systemic inflammation
Case Simulation

A young lady, married, 32 yo, came to

hospital with chief complaint of epigastric
pain localized
What questions should you ask to this
patient?
 This lady have a fever since 1 weeks ago,
abdominal distention in epigastric, vomitus,
history of bloody diarhea, no history of
dyspepsia before
What examinations should you perform to
this patients?
 From examination, there are icteric, pain
and palpable mass in epigastric, dark tea
color urine, no cley-color stool, no defanse
muscular
What working diagnostic and differential
diagnostic are possible in this patient?
 The working dignostic in this patient is left
lobe hepatic abcess
The differential diagnostic are pancreatic
neoplasm, gastric mass, pseudocyst of
pancreas, left lobe hepatoma, colon mass,
lymphoma, aortic aneurism.
What are next examinations you suggested
to confirm a diagnostic ?
What is the treatment ?