Western+Diagnosis+-+Gastrointestinal+System

Emergencies: Abdominal Pain Gastrointestinal (GI) Bleeding Intestinal Obstruction Appendicitis Peritonitis Pancreatitis Gastroesaphageal Reflux (GERD) Hiatus Hernia Gastritis Peptic Ulcer Diarrhea Constipation Gastroenteritis Malabsorption Celiac Disease Crohn's Disease Ulcerative Colitis Irritable Bowel Syndrome (IBS) Diverticular Disease Hemorrhoids Proctitis Liver Disease Fatty Liver Disease Hepatic Fibrosis Liver Cirrhosis Hepatitis Cholelithiasis Cholecystitis Stomach Cancer Pancreatic Cancer Colorectal Cancer Liver Cancer

Anatomy and Physiology
1. CHO digestion 1. tube with functional sphincter at each end 1. secretion of IF, HCl, pepsin 2. IF & HCl from parietal cells 1. duodenum, jejunum, ileum 2. absorption of liquids, macro & micro nutrients 1. exocrine: bicarbonate & enzymes 2. endocrine: insulin & glucagon 1. metabolic, excretory, immunologic functions 2. bile a. 1 liter/day b. common bile duct into SI near pancreatic duct 1. stores bile 2. excreted when needed to solubilize dietary TG 1. caecum, ascending, transverse, descending, sigmoid, rectum, anus 2. mucous secretion 3. absorption of water, electrolytes 1. RUQ, LUQ, RLQ, LLQ
 * Mouth & pharynx**
 * Esophagus**
 * Stomach**
 * Small intestine**
 * Pancreas**
 * Liver**
 * Gall bladder**
 * Large intestine**
 * Abdominal quadrants**
 * Abdominal regions**

History
A. appetite, weight change B. trouble swallowing, heartburn, belching, indigestion C. nausea, vomiting, vomiting of blood, gas, swelling or fullness in abdomen, abdominal pain or cramps D. frequency, amount, color of bm; change in bowel habits; straining at stool; constipation; diarrhea; fat or undigested food in stools; black tarry stools; white or pale stools E. blood in stools, recta bleeding, hemorrhoids F. jaundice, hepatitis G. diet history ---likes, dislikes, typical daily intake (diet diary) ---amelioration or provocation of sx by food ---food sensitivities H. coffee, alcohol, tobacco I. stress, exercise J. travel in or out of country, camping K. past hx of any GI disorders: abdominal surgeries L. family hx of GI disorders

Physical Exam
1. empty bladder 2. comfortable supine position 3. arms at side 4. short fingernails, warm hands and stethoscope 5. slow, firm, gentle - use whole hand 6. may need to initially place pt.’s hand under your own 7. examine tender areas last 8. watch pt.’s face as you palpate 9. systematic 10. stand on pt.’s right side 1. skin a. scars, rashes, lesions 2. umbilicus a. infl, hernia 3. contour, symmetry, masses 4. peristalsis 5. pulsations 1. must do before percussion or palpation 2. listen in all 4 quadrants a. frequency and character of bowel sounds: 5-34/minute; borborygmus - stomach growling b. bruits 1. percuss all 4 quadrants: tympany, dullness 2. liver: ascertain lower border - dullness 1. warm hands 2. pads of fingertips 3. smoothly without short quick jabs 4. knees elevated by pillow 5. pt.’s hand under yours 6. light a. for relaxation of pt. b. abdominal tenderness, superficial masses 7. deep a. in all 4 quadrants b. masses: location, size, shape, consistency, tenderness, pulsations, mobility c. tenderness: rebound d. liver ---left hand under pt.’s right 11th & 12th ribs ---right hand inferior to costal margin ---press in and up ---have pt. take deep breath ---feel for edge of liver e. spleen ---not digestive organ but palpated with abdominal exam ---reach over pt. with left hand and pull left rib cage up towards you ---palpate with right hand as for liver f. kidney ---not digestive organ but palpated with abdominal exam ---left hand under pt. between rib cage and iliac crest ---right hand inferior to costal margin ---press hands together ---reach over pt. with left hand and perform same maneuvers for left kidney g. aorta ---press firmly into abdomen just superior to umbilicus and just to left of midline ---bring both hands together towards midline and feel for pulsation between fingers h. anus and rectum ---standing with hips flexed and upper body resting across exam table ---lateral recumbent ---inspect for infl, rashes, masses ---have pt. bear down ---digital rectal exam ---lubricated glove
 * General**
 * Inspection**
 * Auscultation**
 * Percussion**
 * Palpation**

Laboratory
A. CBC: infections, anemia B. ESR: inflammation C. chem screen: ---liver enzymes a. alkaline phosphatase, 5’-nucleotidase, GGT (gamma glutamyl transferase), AST (aspartate transaminase - SGOT), ALT (alanine transaminase - SGPT), LDH (lactic dehydrogenase) ---bilirubin ---serum proteins D. serum amylase - pancreatitis E. stool cultures F. O & P - ova and parasite exam [Dr. Coletto likes Genova labs] G. fecal fat H. comprehensive stool analysis I. fecal occult blood J. d-xylose absorption - urine

Imaging
A. plain film of the abdomen - supine and upright B. ultrasound C. CT scan D. MRI

Special Studies
A. upper GI series: ---barium swallow usually with small bowel follow through ---fluoroscopic exam B. lower GI series ---barium enema ---fluoroscopic exam C. endoscopy ---gastroscopy: stomach and duodenum ---colonoscopy ---sigmoidoscopy ---anoscopy D. cytology E. biopsy: with endoscopy; percutaneous needle biopsy F. nasogastric intubation: gastric analysis G. radiotelemetry [Heidelberg capsule to test body's pH adaptation] H. pH I. oral cholecystogram J. endoscopic retrograde cholangiopancreatography K. laparoscopy L. laparotomy

Emergencies
A. pain, especially acute and severe, is an intra-abdominal disorder B. must obtain meticulous history C. is abdomen distended or contracted? peristalsis observable? D. no bowel sounds E. palpate deeply and gently: Murphy’s sign [Gallbladder inflammation], McBurney’s point [appendicitis] F. if Nausea and/or Vomiting precede onset of pain, surgery not likely G. fever H. must decide quickly if pt. has a surgical abdomen ---gangrene and perforation can occur in as little as 6 hours after interruption of intestinal blood supply ---"never let the sun set on an acute abdomen”