Patient’s history
· Chronological sequence of events
o Pain then N/V= appendicitis
o N/V then Pain= gastroenteritis
· Sudden or gradual onset of pain
· Character of pain
o Autonomic nerves innervate the viscera
§ Visceral pain- dull, cramp like, insidious
o Somatic nerves innervate parietal peritoneum
§ Somatic pain- localized sharp constant
· Duration of pain
o Pain for hours to days is often more severe than pain lasting for weeks
· Location of pain
o May not be specific
o Referred pain diaphragmatic irritation- kehr's sign
o Periumbilical going to the right lower quadrant- appendicitis
o Changes in location marker of progression
· Palliation
o Use of heat or ice- musculoskeletal origin
· Medications: ASA, ibuprofen
· Relation to food- duodenal ulcer- pain 2 hours after meals relieved by eating
· Relation to food- worse with eating- gastric ulcer
· Movement- peritonitis, fatty food- billiary colic comes with cholithiasis
· Severity of pain scale 1/10
o Single rating is not much clinical help
· Serial determinants of pain severity- useful
· Temporal nature of pain
o Awaken patients at night?
· Post prandial- cholelithias or gastric ulcer
· Randomly through day vs at a certain time
· Fever chills- infection
· Nausea, vomiting, diarrhea, constipation
· History of severe retching/vomiting- mallory-weiss (tear) or boerhaave's syndrome (triad- vomiting, subcutaneous emphysema and LLQ pain)
· Urinary and bowel habits- change in caliber of stool- cancer makes it pencil thin
· Last menstrual period, sexual and pregnancy hx
· Upper resp tract symptoms- lower lobe pneumonia as cause of abdominal pain
· Family social medical history
· Cardiac history-atypical acute MI- stomach pain in women or silent MI in elderly and diabetics
· a-fib-abdominal vascular infarction- mesenteric ischemia
o test is mesenteric angiography
o FOB is positive
· Exposure history- corrosive esophagitis
o Caustic chemicals, lead
o Alcohol or narcotic withdrawal
o Mushrooms ticks (deer tick) spiders (black widow)
o Travel
· Appearance
o Pain constant (parietal, lying still) vs. crampy (gall bladder, cant sit still)- still vs. writhing
o Diaphoresis- acute MI sepsis or shock
o Pallor anemia shock
· Vital signs
o Orthostatics- 3rd spacing or volume depletion- acute pancreatitis
· Heent and neck
o Sclera icterus (jaundice greater than 2.5)
o Fundoscopic signs of emboli (A-Fib)
o Carotid bruits
· Chest
o Crackles and wheezes at bases
· Consolidation, pulmonary edema
· Heart murmurs
· Pleural rubs
· Hard stool- constipation/impaction may have diarrhea
· Pelvic genital and rectal exam on every patients with severe abdominal pain
· Cervical motion tenderness PID- Shandeliar Sign
·
· Adnex mases of the testicular portion can also present as abdominal pain
· **adhesions ms cause of acute bowel obstruction with surgery
· Abdomen palpate from area of least pain to areas with most pain
· Inspection: scars (adhesions, rash (herpes zoster), visible pulsatile masses AAA
o **Adhesions are the most common cause for acute small bowel obstructions in patients without virgin abdomens
o MCC of SBO without surgeries is hernia
· Auscultation: bowel sounds- least revealing! Abdominal bruits
· Percussion: identify ascites- shifting dullness to percussion
· Palpation
o Obtaining rebound tenderness is most often unnecessary and unkind to the patient pain with cough has similar specificity and sensitivity
· CBC with diff: inflammation like IBD which would be UC and Crohn’s or infection
Serum electrolytes
· BUN and Creatin, urinalysis (UTI), UCG (pregnancy)
o Metabolic causes, dehydration, UTI, pregnancy
· Liver function tests: AST (alcohol), ALT (viral)
· Pancreatic enzymes- amylase, lipase (more specific)
· Cardiac enzymes- CKMB, troponin
· Elderly patients: pain presentation is often atypical in location and severity; may not mount febrile response. We may see hypothermia or nothing at all.
· Immunosuppressed patients; steroids may mask pain and decrease inflammation, immunosuppression leads to opportunistic infections and may cause the following diseases: CMV, lymphoma
· In an obese patients organs are not in place where you think they are there is overall abdominal distortion
· Patients on medication: some medications may change the perception of pain or cause constipation
· Pregnancy: distorted abdomen may be difficult to examine, variable organ location. Symptoms of preg my mimic those of some gasteroenteritis i.e. N/V, electrolyte disturbances and dehydration
Imaging studies:
· Upright supine
o Intraperitoneal free air obstruction
o Air fluid levels and dilated loops of bowels specific for bowel obstruction
o Colon cutoff sign is acute pancreatitis
Abdominal pelvic ultrasound- modality of choice for RUQ pain and Gyn disease
CT scan- evaluates intrabdominal infections vasculature inflammation and solid organs
§ Diagnostic test of choice Appendicitis, diverticulitis, pancreatitis
§ Not good for gall bladder and pelvic organs
· MRI scan- not much use in diagnostic workup of abdominal pain
· EKG- rule out ischemia and mi
· Diseases of esophagus
GERD
· Recurrent reflux of gastric contents due to
· Weak or incompetent lower esophageal sphincter
· Decreased resting pressure of LES
· Prolonged or transient relaxation of LES
· Conditions pregnancy scleroderma
· Drugs: anticholinergics, b-adrenergic, CCB
· Substances: nicotine alcohol
· Foods: chocolate, peppermint, and nitrates.
· All Aggravate the lower esophageal sphincter pressure and promotes reflux
· Delayed gastric emptying in gastroporesis in diabetics
· Esophageal will begin to occur in a pH less than 4
Clinical manifestations
· Heartburn- MC
· Regurgitation
· Anemia
· Cough hiccups
· Dysphagia to solids- because you have mucosal damage
· Recurrent laryngitis
· Reflux induced asthma
· Diagnosis
o Barium swallow upper gi series
o Endoscopy with biopsy
o Esophageal manometery: evaluates LES pressure- motility disorders
o Esophageal 24 hour pH monitoring- diagnostic test of choice
· Treatment: lifestyle changes
· Avoid eating prior to sleep weight loss
· Avoid aggravating acidic foods
· Avoid tight fitting clothes
· Antacids: calcium, mg, bicarbonate. Taken before meals and at bedtime
· H2 receptor antagonists: cimetidine, pepsid
· *Proton pump inhibitor: omeprazole. Most potent*
· Promotility agents: metoclorpramide
· Surgery: nissen fundoplication. Indicated in Barretts esophagus when PPI doesn’t work or when we have extra esophageal signs of GERD
· Complications:
o stage one is hyperemia, stage two is linear non-confluent lesions, and stage three is circular confluent erosions (Barretts Esophagus)
o persistent reflux can produce cycle of mucosal damage that causes hyperemia edema and erosion to surface leading to strictures PUD gi bleed
· Barretts esophagus
o Normal squamous mucosa replaced by columnar epithelium
o Premalignant state
o Dx: endoscopy with biopsy
o Tx: same as Gerd, serial biopsies for high grade dysplasia
Corrosive esophatitis
· Chemical burn to upper gi mucosa due to ingestion of alakaline or acidic substances, bleach or detergents, assc. with suicide attempts
· Clinical manifestations
o Burning oropharyngealk and or retrosternal pain
o Poropharyngeal erythema burns erosions ulcers. Even if you don’t see burns in the mouth does not mean that they don’t exist further down in the esophagus
o Excessive gagging dysphagia odynophagia, drooling
o hematemesis, melena
o Diagnosis clinically established. Within 24 hours make sure you do an upper endoscopy to check for grade of damage
· Treatment supportive (IV fluids) no inducing emesis
o Steroids and broad spectrum antibiotics initially
§ Steroids given to prevent stricture
o Surgery esophagogastrectomy, colon interposition
· Complications stricture, formation cancer risk
Esophageal cancer
· There are 2 types; in the past SCC accoutered for more than 90% of cases
Squamous cell carcinoma
· Incidence higher in African men
· MC location upper and mid thoracic esophageous
· Risk factors
o Alcohol and tobacco use
· HPV **achlasia** plumner vinson syndrome (esophageal web, iron deficiency anemia, and glossitis)
· Caustic ingestion, nasopharyngeal carcinoma
Adenocarcinoma
· Incidence higher in white men
· Mc location distal 1/3 esophagus gastroesohpageal junction
· Risk factor
o Gerd, barretts
o Alcohol and tobacco
· Prognosis is very poor
Clinical features
· Dysphagia (difficulty): mc symptoms; initially solids and then liquids
· Anorexia wieght loss- 2nd MCC
· Odynophagia (painful) late finding
o Suggests mediastinum invasion
· Hematemsis chest pain
· Hoarseness
· Aspiration pneumonia and resp symptoms once the cancer has spread to the tracheal bronchial tree
Diagnosis
o Barium swallow- outline a diverticula
o Upper endoscopy with biopsy: definitive dx***
o Full metastic workup
o Ct scan of chest and ab
Treatment
§ Palliation is goal
§ Surgery; esophagetctomy may be curative
§ Chemotherapy and radiation before surgery
Mallory-Weiss syndrome
· Inadequate relaxation of the esophageal sphincter during vomiting with subsequent mucosa tearing of the gastroesphageal junction
· Hematemesis status post retching episode
· Amount may vary- from blood streaked to massive frank blood
· Risk factors: alcoholics bulimics
· Diagnosis: upper endoscopy but may not be necessary because 90% self resolve
o If not, then you will do endoscopy: local injection, sclerotherapy or cautery or surgery if we need to repair the tear
Boerhaves syndrome
· Complete full thickness longitudinal rupture of distal esophagus usually above gastroesohpageal junction- stomach contents empty into the peritoneal
· Triad: vomiting, chest pain, subcu emphysema
· Homan’s Crunch
· Risk factors: sudden increase in intra abodminal pressure caused by retching vomiting heavy lifting childbirth
· Dyspnea diaphoresis
· DX: upright CXR- air in mediastinum, esophagram- usually don’t do because pt is not stable
· Tx: surgical repair broad spectrium antibiotics
Benign esophageal stricture
· Sequelae of prolonged reflux esophagitis
· s/s heart burn solid food dysphagia
· Dx: barium swallow endoscopy
· Tx: balloon dilation catheters
Esophageal web: plummer vinsons syndrome
· Located in upper 1/3 of esophagus
· Higher risk factor for squamous cell carcinoma (10% will develop into oral and esophageal carcinoma)
· Causes: dysphagia, iron deficiency anemia, atrophic oral mucosa, coroenichia (spoon shaped finger nails)
· Treatment esophageal dilation that will break the web and iron supplements
Esophageal rings: schatzki rings
· A circumferential ring in the lower esophagus, usually accompanied by a sliding hiatial hernia
· MC occurs at the squamous columnar junction
· Usually asymptomatic
· Mild to moderate dysphagia and reflux can occur if you have that hernia
· If there is no reflux all you have to do is dilate the esophagus. If theres reflux you have to dilate the esophagus and Anti-reflux surgery which is the Nissan fundopigation
Esophageal diverticula
Three types: traction, zenker’s, and epiphrenic
· Most esophageal diverticula are saved by an underlying motility disorder
Zenker's diverticulum: (pulsation, failure of the cricopharengeal muscles to relax during swallowing) mc esophageal diverticula
o Mucosal herniation found in upper 1/3 of esophagus
· S/S: dysphagia regurge (solid food) halitosis weight loss cough
· Tx: surgery. Be careful with endoscopy because you don’t want to perforate
Traction diverticulum (traction, being pulled on by lymphadenopathy) asymptomatic no treatment
· Located at mid-point of esophagus near tracheal bifurcation
· Traction from continuous mediastinal inflammation and adenopathy causing retraction of esophagus pulmonary TB or sarcoidosis
Epiphrenic diverticulum (pulsation) often asymptomatic
· Mucosal herniation found in lower 1/3 of esophagus
· Assc with spastic dysmotlity or **achlasia**
· Dx: barium swallow
· Tx: surgery
Achlasia
· Acquired disorder of esophageal smooth muscle
· LES fails to completely relax with swallowing
· Abnormal peristalsis of the esophageal body in the lower third because the neuroplexus is missing
· Causes: idiopathic, assc. with gastric cancer
· Ss: dysphagia odynophagia CP weight loss nocturnal cough recurrent bronchitis or pneumonia
· Equal difficulty in swallowing solids and liquids
· Wash food with lots of water, twist their necks to help the food to go down
Diagnosis
· Barium swallow: birds beak narrowed distal esophagus with large dilated proximal esophagus
· Endoscopy required to exclude malignancy because achlasia is risk factor
· Esophageal manometry confirms Dx. Because manometry is the best test for motility disorders
Treatment adaptive measures: chew food better, don’t eat before bed
· medical therapy includes CCB, sublingual nitroglycerin, and injection of botulism into the LES, dilation to the LES ring and surgery
Diffuse esophageal spasm
· Non peristaltic spontaneous contraction of esophageal body
· Several segments contract simultaneously preventing appropriate advancement of food bolus
· Complain of both chest pain and dysphagia
o Nutcracker esophagus more complaint on chest pain** because the spasm is of higher amplitude
· In contrast to achlasia LES function is normal. Food will go to stomach
· Ss non cardiac chest pain that mimic angina, dysphagia is common, regurgitation of food is uncommon
· Diagnosis esophageal manometry: simultaneous repetitive contraction that occur after swallowing with normal LES response
· Barium swallow cork screw: multiple spontaneous contractions
· Treatment nitroglycerin CCB TCA
Hiatal hernias
· Sliding account for greater 90 of cases
· Both gastroesophageal junction and portion of the stomach herniate into the thorax through the esophageal hiatus
· Les is above the diaphragm
· Medical- antacids, small meals, elevation of trunk
o 10% require nissen's
· Presents with a several month history of intermittent dysphagia foods such as steak seem to get stuck
· He is able to clear these foods by drinking extra liquids symptoms are not getting worse: lower esophageal ring shitake’s ring
· A 65 y/r male. Trouble swallowing for 5 weeks. At first only meat stuck in his through now trouble with soft foods. No hx of similar problems or of any gi problems. He is a moderately heavy drinker and has smoked 1 pack per day for 40 years
· Esophageal cancer
· Presents sp having dry heaves after drinking- mallory weiss
Acute gastiritis
· Diffuse or localized inflammation of gastric mucosa
Etiology
· Aspirin nsaids alcohol smoking
· H. pylori infection, severe illness/stress
· Ss: epigastric burning and pain n/v gi bleed
· Diagnosis: endoscopy with or without biopsy
· Gastric mucosa may appear congested friable with superficial ulcerations or petechia
· Treatment remove offending agent
· Antacids h2 receptors antagonist PPI
· Antibiotics for h. pylori
Chronic gastritis
· Autoimmune gastritis assc with
o Parietal and gastric cell antibodies pernicious anemia
· Low chloride levels
Etiology
· Helicobacter pylori infection
· Diag: endoscopy with biopsy
· Tx: h. pylori, irradication
PUD
· Areas of discrete GI tissue destruction occurring mostly in the proximal duodenum and stomach
· More common in men
· MCC: h. pylori and nsaids
· Acid hypersecretion states: zolinger elisson syndrome
· Caused by combination of impaired mucous defense and acid gastric contents
Clinical manifestation
· Epigastric pain
· Duodenal ulcers: caused by increase in offensive 70-90 of patients low very rare, younger patients, nsaids, eating relieves pain
· Gastric: older patients, smoking, more complications higher recurrence
Diagnosis: endoscopy most accurate
· Barium swallow: less reliable
· Upright x-ray for perforation
· Lab tests for h. pylori infection
Treatment: supportive alter all risk factors
· Acid suppression
· Eradicate h. pylori infestation
· Cytoprotection
· Misoprostol
· Surgery required for complications
Gastric cancer
· Rare in the us
· MC: adenocarcinoma
· Risk factor severe atrophic gastritis gastric dysplasia
· Gastric polyps
· H. pylori infection
· Pernicious anemia