Gastroenterology
Ambulatory Medicine Clerkship
Scott Grisolano, MD
Division of Gastroenterolgy and Hepatology
KUMC
Outline
• Physical exam
• History taking
• Evaluation of abdominal pain
– Common Clinical Scenarios
– Differential diagnosis
Physical Exam - Abdomen
• Inspection
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Skin
Hernia
Contour
Pulsations, peristalsis
• Auscultation
– Bowel sounds
– Bruits
• Percussion, Palpation
– Liver, spleen, masses, aneurysm
– Peritoneal irritation
• Rigid abdomen, guarding, rebound tenderness
• How was the ride to the ER?
• blunted: elderly, severely ill
• HEENT
– Scleral icterus
– Conjunctival pallor
• Skin
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Jaundice
Spider angiomata
Gynecomastia
Petechiae, bruising
Caput medusae
• Extremities
– Palmer erythema
• Abdomen
– HSM
– Ascites
• Neurological
– mentation
– Asterixis
• Anorectal
– Perianal exam
– DRE
– Stool
Painful History
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Location
Onset, frequency, duration, severity
Quality
Radiation
Factors that exacerbate or improve symptoms such as
food, antacids, exertion, defecation
• Associated symptoms: fevers, chills, weight, N, V,
diarrhea, constipation, hematochezia, melena, jaundice,
change in the color of urine or stool, change in the
diameter of stool
• Family history of bowel disorders
• Medications: OTC (acetaminophen, aspirin, and NSAIDs)
• Menstrual history in women
Embryology - Pain - Artery - Organ
• Foregut – Epigastrium
– Celiac – S, D
• Midgut – Periumbilical – SMA
– J, I, TC
• Hindgut – Hypogastrium – IMA
– TC, R
Pain
• Visceral pain (viscus)
– diffuse, poorly localized
– gnawing, burning, cramping
• Somatic pain (abdominal wall, parietal peritoneum)
– more intense, better localized
• Referred pain
– same dermatome
– sharp, well localized; resembles somatic
Abdominal Pain - Triage
• Acute
– Sick patient?
– High level of suspicion in immunosuppressed,
elderly
– Abdominal examination
• Chronic
Abdominal Pain - Triage
• History
– differential diagnosis
• Examination
– vital signs
• Labs
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CBC
CMP
Liver biochemistries
Amylase, lipase
UA
Pregnancy test
• Abdominal x-ray
Ruptured or Perforated Viscus
- PUD, ectopic pregnancy, dissecting aneurysm
Obstruction of Viscus
- adhesions, hernia, volvulus, intussusception
Ischemia
- mesenteric, PE, MI
Inflammation
- pancreatitis, cholecystitis, appendicitis, diverticulitis
Peritonitis
Abdominal Pain - Triage
• History
– differential diagnosis
• Examination
– vital signs
• Labs
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CBC
CMP
Liver biochemistries
Amylase, lipase
UA
Pregnancy test
• Abdominal x-ray
RUQ Pain
• Liver, biliary tree
– May radiate to back, epigastrium
• Pancreatitis
• Cardiac
• Pleural/pulmonary
• Nephrolithiasis
Epigastric Pain
• Acute pancreatitis
• PUD
• GER
• Cardiac
• Pleural/pulmonary
Lower Abdominal Pain
• Distal intestinal tract
• Urinary tract
• Pelvic structures
– Colonic, SB source = diarrhea, hematochezia
– Rectal source
= urgency, tenesmus
Lower Abdominal Pain
• LLQ
– Diverticulitis
– Colitis
• Infectious, ischemic, IBD
• RLQ
– Appendicitis
– ileocolitis
Lower Abdominal Pain
• Females
– Menses, dysmenorrhea, dyspareunia
– Possibility of pregnancy
– Vaginal discharge, bleeding
– Adnexal cysts
– Ovarian torsion
– Ectopic pregnancy
– PID
Specific Conditions
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PUD
Gallbladder disease
Acute pancreatitis
Small bowel obstruction
GI bleeding
Specific Conditions
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PUD
Gallbladder disease
Acute pancreatitis
Small bowel obstruction
GI bleeding
PUD
• Duodenal ulcer
– symptoms of occur when acid is secreted in the
absence of a food buffer
– symptoms occur 2-5 hours after meals or on
empty stomach
• Gastric ulcer
– more severe pain occurring soon after meals,
with less frequent relief by antacids or food
PUD
• Epigastric pain in 2/3 symptomatic patients
– may localize to the RUQ, LUQ
– burning, gnawing, or hunger-like in quality, may be
vague
• Sudden development severe, diffuse abdominal
pain may indicate perforation
• Vomiting is the cardinal feature in pyloric outlet
obstruction
• Hemorrhage may be heralded by nausea,
hematemesis, melena, or dizziness
PUD - Etiology
• Helicobacter pylori
• NSAIDs
< 5%
30-50%
Alarm Symptoms / Red Flags
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Age > 50
Weight loss
Dysphagia
Persistent vomiting
Palpable abdominal mass
Occult gastrointestinal bleeding
Otherwise unexplained anemia
Family history UGI malignancy
Previous gastric surgery
Specific Conditions
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PUD
Gallbladder disease
Acute pancreatitis
Small bowel obstruction
GI bleeding
Gallbladder
• Biliary colic
– Pain reaches crescendo then resolves completely
– Pain is visceral in origin (no true gallbladder wall
inflammation)
– Pain resolves when the gallbladder relaxes,
permitting stones to fall back from the cystic duct
• Acute cholecystitis
– RUQ pain lasting > 4-6 hours should raise suspicion
for acute cholecystitis
– Symptoms of malaise, fever more likely
Cholecystitis – Clinical Presentation
• Abdominal pain
– RUQ, epigastrium
– may radiate to the right shoulder or back
• Pain is steady and severe
– nausea, vomiting, and anorexia
• Prolonged RUQ pain (> 4-6 hours),
especially if associated with fever, should
arouse suspicion for acute cholecystitis as
opposed to an attack of simple biliary colic
Differential Diagnosis
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Acute pancreatitis
Appendicitis
Acute hepatitis
Peptic ulcer disease
Diseases of the right kidney
Right-sided pneumonia
Fitz-Hugh-Curtis syndrome
– perihepatitis caused by gonococcal infection
• Sub-hepatic, intra-abdominal abscess
• Perforated viscus
• Cardiac ischemia
Cholecystitis – Labs
• Bilirubin, AP generally normal in uncomplicated
cholecystitis
– biliary obstruction is limited to the gallbladder
• If bilirubin, AP elevated this should raise concerns
about complicating conditions such as cholangitis,
choledocholithiasis
– mild elevation in serum aminotransferases and amylase,
and hyperbilirubinemia with jaundice have been reported
even in the absence of these complications
• These abnormalities may be due to the passage of small stones,
sludge, or pus
Cholecystitis – Physical Exam
• Ill appearing, febrile, and tachycardic
• Lie still on exam table because cholecystitis is
associated with local parietal peritoneal
inflammation that is aggravated by movement
• Abdominal examination usually demonstrates
voluntary and involuntary guarding
• "Murphy's sign" may be a useful diagnostic
maneuver
Acute Calculous Cholecystitis
Specific Conditions
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PUD
Gallbladder disease
Acute pancreatitis
Small bowel obstruction
GI bleeding
Acute Pancreatitis - Etiology
• Gallstones (45%)
80%
• Alcohol abuse (35%)
• Post-ERCP, medications, metabolic, hereditary,
infectious, connective tissue disease, trauma,
congenital anatomic abnormalities, tumors (10%)
• Idiopathic (10%)
• Overall mortality 10 -15%
– severe disease as high as 30%
• Males (alcohol) > Females (choledocholithiasis)
Acute Pancreatitis – Clinical
Presentation
• Mid-epigastric abdominal pain
– Steady, boring pain
– Radiation to the left upper back
• Anorexia, nausea  vomiting  diarrhea
• Low grade fever
• Presentations associated with complications
– Shock
– Multi-system failure
Acute Pancreatitis – Physical Exam
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Abdominal tenderness
Fever (76%)
Abdominal guarding (68%)
Abdominal distension (65%)
Tachycardia (65%)
Hypoactive bowel sounds
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Jaundice (28%)
Dyspnea (10%)
Hemodynamic changes (10%)
Melena or hematemesis (5%)
Cullen’s sign
The Grey-Turner sign
Left pleural effusion
Acute Pancreatitis - Diagnosis
• Serum amylase
– Not specific for pancreatitis
• intestinal ischemia, renal insufficiency, small bowel obstruction,
macroamylasemia, parotitis
– Short half-life: elevates early, returns to normal early (within 2-3 days)
• Serum lipase
– More specific to pancreas
– Long half-life: levels rise later, stay elevated for longer (7-14 days)
• Liver enzymes
– ALT, AST, alkaline phosphatase, total bilirubin
– ALT > 150 in patient with cholelithiasis suggests gallstone pancreatitis
Acute Pancreatitis - Diagnosis
• Ultrasound
– Most useful initial test for common bile duct dilation
and gallstones
• Contrast CT Scan
– Not necessary for diagnosis of acute pancreatitis
– May help identify etiology in rare instances (tumor)
– Useful to assess complications - fluid collections or
pancreatic necrosis
Pseudocyst
- takes > 4 weeks to
develop pseudocyst
Acute Pancreatitis - Severity Staging
Ranson Criteria - > 3 indicates severe AP
• At Admission
– Age > 55; WBC > 16K; Glucose > 200; LDH >350; AST > 250
• During first 48 hours
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Hct decrease by > 10% with hydration
BUN increase > 5 mg/dL
Calcium < 8 mg/dL
pO2 < 60 mm Hg
Evidence of fluid sequestration (> 6L replacement
needed)
Specific Conditions
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PUD
Gallbladder disease
Acute pancreatitis
Small bowel obstruction
GI bleeding
Small Bowel Obstruction
• Post-operative adhesions
• Hernia
• Tumors
SBO - Symptoms
• Abdominal distention, vomiting, crampy pain
• Abdominal pain
– Periumbilical, crampy
– paroxysms of pain every 4-5 minutes
– presence of constant abdominal pain or change of pain
from colicky to constant suspect strangulation
• Patients may or may not complain of obstipation
and inability to pass flatus since colon requires 1224 hours to empty after the onset of bowel
obstruction
SBO – Physical Exam
• Fever, tachycardia: associated with strangulation
• Inspection
– surgical scars, degree of distention
• Auscultation
– may reveal high-pitched or hypoactive bowel sounds
• Percussion, Palpitation
– Tenderness to percussion, rebound, guarding, and localized
tenderness suggests peritonitis
– Tympany usually present due to air-filled loops of bowel or stomach
– abdominal mass may indicate an abscess, volvulus, or tumor
– Search for inguinal, femoral, and incisional hernias
• Rectal examination
– gross or occult blood can be found with neoplasm, ischemia, and
intussusception.
SBO – Labs
• Leukocytosis: may indicate presence of
strangulation
• Metabolic alkalosis: seen with frequent emesis
• Metabolic (lactic) acidosis: ischemic bowel
SBO – X-rays
• Upright chest film to rule out the presence of free air
• Supine and upright abdominal films
– Multiple air-fluid levels with distended loops of small bowel are seen
in small bowel obstruction, although occasionally can be seen in
setting of paralytic ileus
• Presence of air in the colon or rectum makes the diagnosis
of complete obstruction less likely, particularly if symptoms
have been present for more than 24 hours
• Plain films:
– equivocal in 20-30% of patients
– normal, nonspecific in 10-20%
SBO – CT scan
• Presence, level (transition point), severity, and
cause may be identified
• Other abdominal pathology can be detected
• Absence of air, fluid in distal small bowel or colon
denotes complete obstruction
• Intestinal pneumatosis and hemorrhagic
mesenteric changes can be seen in advanced
strangulation
• In most cases of SBO, no obvious source of
obstruction is seen, since adhesions cannot be
detected by CT scan
SBO - Management
• "never let the sun rise or set on a small
bowel obstruction"
Specific Conditions
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PUD
Gallbladder disease
Acute pancreatitis
Small bowel obstruction
GI bleeding
All bleeding is not the same…
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Where is it coming from?
Pace of bleeding?
Volume of bleeding?
Associated symptoms?
Color of blood?
What color blood?
• Melena
• Hematochezia
• Occult blood positive
Acute GI Bleeding
UPPER >
75-80% vs.
LOWER
20-25%
Acute GI Bleeding
• Assessment, stabilization, resuscitation
• Medication review
– Anticoagulants (Coumadin)
– Antiplatelet agents (Plavix)
– Aspirin, NSAIDs
Clinical Prognostic Factors
Older age (>60)
Severe comorbidity
Altered hemodynamics
- Tachycardia
- Orthostasis
Transfusion
> 100 bpm
> 20 mg Hg systolic
> 10 mg Hg diastolic
-  4 - 6 units/resuscitation event
Severe coagulopathy
Inpatient status at time of bleed
UGI Bleeding
• EGD
– Diagnosis
• identifies bleeding site (90-95%)
• prognostic value
– Endoscopic Therapy
• Medical Therapy
– IV Proton Pump Inhibitors (PPIs)
– octreotide
Active Bleeding - Dieulafoy
Lesion
90%
Esophageal Varices
LGI Bleeding
• LGIH accounts for 20-25% of all GI bleeds
• Definition: distal to the ligament of Treitz
• Colonic lesions account for vast majority
• Majority cease without intervention
• 15-20% require intervention
LGIB - Etiology
* post-polypectomy bleeds
LGI Bleeding
• Urgent Colonoscopy
– After rapid oral purge
– Diagnosis
• identifies bleeding site 54-80%
– Treatment
• epinephrine, heater probe, bipolar, hemoclips
Diverticular Bleed
Post-polypectomy - NBVV
Ischemic Colitis