Clinical

Clinical examination
examination in
in
digestive
digestive tract
tract
diseases
diseases
 The main function of
oesophagus – transportation
of aliments from pharynx to
stomach.
Oesophageal syndromes
1. Gastro oesophageal reflux
disease (GERD) – presence of
symptoms produced by the reflux
of gastric content in oesophagus
(pirosis, pain) or presence of
endoscopic changes due to
oesophageal reflux.

GE Reflux becomes pathological when

the antireflux mechanisms do not work.
• Oesophagitis
• Oesophageal tumours
• Oesophageal diverticulus
• Hiatus hernia – abnormal
protrusion of a stomach portion
through diaphragmatic hiatus
into the thorax.
• Barret Syndrome – replacement
of normal mucosa with intestinal
type mucosa in the distal part of
oesophagus; a potential of
carcinoma formation .
• Achalasia of cardia – lack of
relaxation of inferior oesophageal
sphincter and absence of
propulsive peristaltic waves of
oesophageal body.
 Symptoms in
oesophageal diseases
• Retrosternal Pain – inflammation,
erosion, Cr.
• Heartburn (pyrosis) – specific
burning feeling; reflux -
oesophagitis.
• Dysphagia - difficult passage of
food
 Symptoms in
oesophageal diseases
• Regurgitation – the return of
swallowed food;
• Foul breath – due to cancer tumour
or congestion of food in oesophagus.
• Oesophageal vomiting
• Haemorrhage (red blood) – ulcer of
oesophagus, foreign body,
degradation of a tumour.
 Functions of the stomach:
• Motoric (reservoir, mixing of food,
regulation of passage of alimentary
bolus)
• Exocrine – secretion of HCl,
pepsinogen, mucus, bicarbonate,
intrinsic factor, gastroferrin, water.
• Endocrine – secretion of gastrine,
somatostatine
 Gastric cells:
1. mucous cells – secrete mucus,
2. oxintic (fundic) glands
• parietal cells – HCl, gastroferrin
(for absorption of Fe), intrinsic
factor (GP for absorption of vitamin
B12);
• peptic cells – pepsinogen;
3. pyloric glands – mucus, pepsinogen,
gastrine, somatostatine.
 Duodenum:
• The bile and pancreatic
ducts are opening
through papilla Vater.

Small intestine (Jejune

and ileum)
• digestion and absorption
of nutritive constituents,
• immune function.
Symptoms in digestive diseases
• Abdominal pain
• GI haemorrhage
• Gastric dyspepsia: Nausea, Vomiting,
Eructation, Regurgitation
• Heartburn (pyrosis)
• Dysphagia
• Deranged appetite
• Intestinal dyspepsia: Meteorysm,
Diarrhoea, Constipation
 Pain in abdomen

caused by excitation of specific

nociceptive nervous receptors
 Mechanical stimuli:
- Stretching of a cavitar organ or of
a solid organ capsule (liver),
- violent muscular contractions
(muscular spasms)
- distensions,
- ulceration,
- perforation.
 Chemical stimuli:
• Chemical substances
• Endogen substances, liberated
in inflammatory processes or
ischemia, able to excite these
receptors (bradichinine,
histamine, PG).
 Character of pain
gastric pain could be dull, intense,
“burning”;
- Localized in epigastria; irradiating to
median line
- Associated with vegetative
manifestations – nausea, transpiration
intestinal pain – has a colic character –
pain periods alternating with periods of
leisure
“dagger” pain in epigastria,
associated with abdominal
with muscle contracture – in
perforation of ulcer

pain due to intestinal ischemia

– severe, non-localized
 in peritonitis (involvement
of parietal peritoneum)
• Pain is localized, severe
• Increases in stretching of
peritoneal membrane, i.e. during
abdominal muscle strain;
• Abdominal muscular tension
• Positive Blumberg sign
 Location of pain
• Retrosternal – involvement of
oesophagus or stomach cardia.
• In epigastria – gastric,
duodenal, biliary, pancreatic
disorders.
• Periumbilical – small intestine
disorders.
• Subumbilical - appendicle,
colonic, pelvic origin
colonic pain – non-localized, in the
hole abdominal cavity
rectal pain – in anal region,
spreading to sacral region
hepatic pain – in right hypochondria
in intestinal occlusion – irradiate to
the back
pain due to gallbladder lesions –
in epigastria, irradiate in right
hypochondria, to right scapula.

pancreatic pain – in left

hypochondria, epigastria, right
hypochondria, like a “belt”.
 Time relationships
• Constant pain – gastric
carcinoma
• Pain in attacks – acute
gastritis, biliary colic
• Periodic pain – reflux
oesophagitis (occurs in the
night time and in clinostatism)
• hungry or nocturnal pain
(awakes the patient from a
deep sleep) - in duodenal ulcer

• seasonal pain - in peptic ulcer

(exacerbation in spring and
autumn)
 Pain with acute onset
(becomes maximal in several
minutes):
• Perforation of a gastro-duodenal
ulcer,
• Dissection of aorta,
• Rupture of oesophagus,
• Extrauterine pregnancy,
• Renal stones
Pain with a maximum in 10-60
minutes:
• Acute pancreatitis
• Cholecystitis
• Intestinal occlusion
• Thrombosis of mesenterial arteries
Relationship between the pain
and ingestion of aliments
• early postprandial pain
(immediately after ingestion up
to 60-90 min postprandial) –
reflects an oesophageal or
gastric disorder.
• late postprandial pain (appears
in 2-3-4 hours after ingestion
of aliments; “painful hunger”)
- in duodenal ulcer, duodenitis,
pancreatic insufficiency
 Relationship between the
pain and administration of
antacids
• pain in ulcer calms down after
ingestion of milk, alkaline
substances, H2-blockers
• pain in gastric cancer does not
respond to antacids, but to
opioid analgesics.
 Abdominal pain due to
extraabdominal causes could be
found in following diseases:
• Pulmonary (pleurisies, pulmonary
infarction)
• Cardiac (myocardial infarction)
• Metabolic (diabetes, tetanus)
• Neurologic (herpes zoster,
radiculitis)
 1. Dysphagia

• Feeling of “blockage” or
obstruction of food passage
through pharynx or oesophagus.
 Types of dysphagia
• Mechanical dysphagia (organic) –
caused by narrowing or intrinsec
compression of oesophageal
lumen (carcinoma, post
ulcerative strictures, a huge
amount - bolus - of food).
• Motorial Dysphagia (functional)
– difficulty in initiating
swallowing, an abnormal
deglutive peristalsis, due to
diseases of oesophageal muscles
(pharyngeal paralysis,
achalasia, spasm).
 Specific
Specific signs
signs of
of
mechanical
mechanical dysphagia:
dysphagia:
1.Difficulty in swallowing of a
solid alimentary bolus, and
only in advanced stages –
including liquid food.
2. Inefficiency of spasmolitics.
Specific signs of motorial
dysphagia:
dysphagia
1.Difficulty in swallowing of a
liquid alimentary bolus, the
solid one passes easier.
2.Spasmolytics are efficient.
 2. Deranged appetite
1. Increased appetite – duodenal
ulcer
2. Anorexia – diminished up to loss
of appetite (gastric ulcer,
cancer)
3. Bulimia – exaggerated feeling of
hunger
4. Aversion for meat – in gastric
cancer
5. Perverse appetite – wish to
eat non-edible substances –
chalk, soil, newspapers etc.
(anaemia, in pregnancy)
6. Citofobia – fear of eating
(gastric ulcer)
 Other functional
symptoms
1. Aphagia – complete
oesophageal obstruction
2. Odinophagia – painful
deglutition
3. Phagophobia (fear of
swallowing and refuse to
swallow) – in isteria, rabies,
tetanus
 General manifestations

• Fever
• Loss of weight
• Deterioration of general
condition
• Deshidratation
3. Nausea
• Feeling of an imminent wish
to vomit, felt in the throat
or epigastria.
4. Vomiting (or emesis)
• explosive forced per oral
elimination of gastric
content.
 Complications of
vomiting:
• Rupture of oesophagus
(Boerhaave symptom)
• linear ruptures of mucosa in the
region of cardio-oesophageal
junction (Mallory-Weiss s-m),
• Dehydration,
• Loss of gastric secretion (HCl) –
metabolic alkalosis with
hypopotasiemia.
 Causes of nausea and
vomiting: I.
• Acute abdominal inflammatory
diseases - appendicitis,
cholecystitis, peritonitis.
• Intestinal occlusion
• Infections
• Diseases of nervous system with
high intracranial pressure
(tumours, encephalitis,
hydrocephaly)
 Causes of nausea and
vomiting: II.
• Acute miocardial infarction
• Metabolic and endocrine
disturbances – uraemia, diabetic
cetoacidosis, suprarenal failure.
• Side effects of some drugs –
digitalis, morphine, histamine,
chemiotherapic drugs.
• Psychogenic causes.
5. Heartburn (pyrosis)
feeling of heat or burning,
retrosternal or in
epigastria; irradiates to the
neck, sometimes in hands.
More often is associated to
gastrooesophageal reflux.
6. Eructation
elimination of gases through
mouth
7. Regurgitation –
elimination of
gastric/oesophageal content in
oral cavity without any effort,
nausea or abdominal contraction
 8.Meteorysm
an increased formation of
intraintestinal gas with abdominal
distension and flatulence.
Appears after:
• Ingestion of specific aliments
(vegetables, some cereals)
• bacterial colonisation of small
intestine (Lambliosis)
 9. Diarrhoea
• Increased daily amount of
stools over 300g; usually
associated with increased
fluidity and frequency of
stools.
• diarrhoea is considered
chronic after 2 weeks
Causes of acute diarrhoea
• Medicines or toxins ingested,
• Administration of chemotherapy
drugs,
• Resumption of alimentation
after a long fasting,
• Clearing of faeces (ex. in
marathon).
 Forms of chronic
diarrhoea:
• Inflammatory
• Osmotic
• Secretory
• Due to motility disturbances
Inflammatory diarrhoea
• Parasite infections – hemlinth, amoeba
• Infections – salmonella, shigella,
E.coli
• Ulcerative colitis, Crohn disease
(autoimmune mechanisms)
• Colitis due to physical agents: toxins –
Hg, Ar, irradiation;
• Ischemic colitis, vasculitis
 Osmotic diarrhoea
Ingestion of osmotically active products:
• Laxative
• Products containing sorbitol, xilitol: chewing
gum
• Medicines: lactulose, almagel (Mg)
Absorption deficiencies
• Deficiency of: disaharide (lactase, sucrose),
enterochinase
• Congenital malabsorption
• Exocrine pancreatic insufficiency
• Diminished absorption surface (short
intestine, inflammation)
 Secretory diarrhoea
• Infections (cholera,
Staphylococcus aureus,
Escherichia coli)
• Tumours
• Some laxatives
• Dihydroxilated biliary acids
 Diarrhoea due to
motility disturbances
Hypermotility
• Irritable intestine syndrome
• Carcinoid syndrome (serotonin)
• Hyperthyroidism
Hypomotility
• Diabetes mellitus
• Hypothyroidism
• Scleroderma
• Amiloidosis
 10. Constipation
the frequency of stools is less than
3 times/week (1 time in 48 hours).

Secondary to this there is an

increased absorption of water – the
stool becomes more consistent.
Constipation is considered chronic
after 6 weeks.
 Causes of constipation
(most frequent)
1. Colon tumour or foreign body,
strictures of the colon,
infections, ischemic colitis,
2. Psychogenic,
3. Functional (reduced intake of
liquids, fibres; reduced
exercise),
4. Rectal diseases, anal channel
diseases,
5. nervous system lesions,
6. metabolic and endocrine diseases
7. intoxications,
8. digestive system diseases,
9. medicines (analgesic, opiates,
antidepressive, antipsychotic,
calcium channels blockers).
 Gastrointestinal
haemorrhage

is an emergency, always
having an organic reason.
 Signs of GI haemorrhage:
1. Haematemesis – vomiting with
blood.
if haematemesis happens in short time
after onset of bleeding, vomiting
masses are red.
if haematemesis happens in 0,5 -1
hours, vomiting masses are dark red,
brown or black, like “coffee ground”
(blood degraded by HCl).
2. Melena – elimination of black
stools, like pitch, “like fuel oil”,
caused by blood from an upper
gastrointestinal haemorrhage
(oesophagus, stomach or
duodenum), digested by microbial
flora and becoming dark.
Lesions of jejunum, ileum and
ascending colon can cause
melena, when the time of
gastrointestinal transit is
prolonged.
 3. Haematochezia
pass of red blood through
rectum, as a sign of bleeding
from a distal source (Treitz
ligament).
 Severity of haemorrhage:
< 500 ml – without clinical signs
signs of hypovolemic shock (loss of
more than 40% blood volume):
• Lipothymia, syncope, nausea,
transpiration and thirst,
• Pale and cold skin
• Agitation,
• Arterial hypotension
• Tachycardia
Aetiology of digestive haemorrhages (DH)

Aetiology of superior DH:

• erosive or hemorrhagic gastropathy
(NAID, anticoagulants, alcohol),
• duodenal or gastric ulcer,
• s-m Mellory-Weiss,
• oesophageal varices
• malign tumours,
• oesophagitis (5-8%), duodenitis (5-9%),
• Angiodysplasia (5-7%),
Aetiology of inferior DH
• Anorectal disease ,
• polyps, cancer,
• diverticulosis,
• abnormal intestinal tract
• enterocolitis, colitis,
• intestinal ischemia
 Clinical examination can reveal
signs of following diseases:

• Oropharyngeal,
• striate muscles,
• neurological: paralysis, dyzartria,
dysphonia, ptosis, atrophy of tongue,
• skin (scleroderma),
• thyroid gland,
• enlarged lymph nodes (metastasis)
 General and special
inspection
1. Weight loss,
2. Skin – Pale and dry; jaundice
3. Facies hyppocratica
(peritonitis)
4. Inspection of lips, teeth,
tongue, oral cavity, palate,
tonsils.
Normal
 Inspection of abdomen
• Contours and peristalsis of the abdomen
• Abdomen dimensions
• Abdomen symmetry
• Divarication of the abdominal rectus
muscles.
• Presence of local bulging (hernia, tumor)
• Skin and subcutaneous fat
• Umbilicus inspection (Position and
protrusion)
• Superficial venous circulation (caput
Medusae )
Obesity
Hepatomegalia
Gallbladder, Jaundice
Ascites, protrusion of
umbilicus
Ascites, protrusion of
umbilicus
Umbilicalal hernia
Umbilical hernia
Superficial venous circulation
 Auscultation of
abdomen
• bowel sounds (garguiments)
• peritoneal sounds
• arterial murmurs.

The method of ausculto –

friction is used to determine
the lower border of the
stomach
Abdomen auscultation
 Percussion of
abdomen
• A method to appreciate the
presence of ascites

• Percussion of liver and spleen

Appreciation of presence of
liquid in abdominal cavity
Appreciation of presence of liquid in
abdominal cavity –
fluctuation (wave) sign
Percussion
 Palpation of abdomen

• superficial (light)
• deep
 The goal of superficial
palpation is to appreciate:
1. Painful regions
2. Big size formations
3. Abdominal muscle strain
4. Hernia of medial abdominal
line
5. Blumberg symptom
 General rules of palpation
1. The doctor is sitting on the right part
of the patient, at the level of the bed.

1. The painful region of the abdomen is

to be palpated at the end.
 The order of superficial
palpation (counterclockwise):
• Left inguinal region
• Left flank (Left lateral region)
• Left hypochondria
• Epigastria
• Right hypochondria
• Right flank
• Right inguinal region
• Suprapubian region
• Umbilical region
 Blumberg symptom
sign of irritation of peritoneum
(positive in peritonitis).
Appreciation:
1. The palpatory hand pushes the
abdomen in the painful region (pain
is present),
2. Take off abruptly the hand. If
pain is intensified the Blumberg
sign is positive.
 Deep palpation
Aim – direct examination of
different parts of
gastrointestinal tract.
Appreciate:
• Dimensions
• Shape
• Presence of irregularities
 The order of deep
palpation:
1. Sigmoid colon
2. Caecum
3. Terminal segment of ileum
4. Ascending colon
5. Descending colon
6. Transversal colon
7. Big curvature of the stomach
8. Pylorus
 Method of deep palpation
of the abdomen

There are 4 consecutive moments

1 moment – placement of the joint fingers
of one hand parallel to the palpated
margin; the other hand is on the abdomen
in order to calm down the patient
2 moment – formation of skin folder
The skin folder is to be formed
To the umbilicus
For part of the colon, situated below the
umbilicus (sigmoid colon, caecum,
ileocaecal angle, ascending colon,
descendent colon)
From the umbilicus
For parts, situated above the umbilicus
(transversal colon, stomach)
3 moment – deepening the fingers
into abdomen (in expiration)
4 moment – sliding on the surface
of the respective organ
Palpation of ascending
and descending colon
 Palpation of ascending
and descending colon
• The left hand is on the
posterior part of the abdomen
(in lumbar region), moving the
tissues to the hand which is
doing palpation (right)
 Palpation of the big
curvature of the stomach
Paraclinic
Paraclinical
al eexam
xamination
ination
1. FEGDS
2. USG
3. CT, MRI
4. Radiography with contrasted
oesophagus (barium)
5. General blood analysis
6. Biochemical analysis of blood