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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 10 GI symptoms
242
Hematemesis ± melena
Vomiting of bright red blood and/or passage of black tarry motions. This
implies bleeding usually from the upper GI tract: esophagus, stomach, and
duodenum.
Some differential diagnoses and typical outline evidence
Bleeding
duodenal ulcer
Suggested by: epigastric pain and tenderness, nausea
Confirmed by: esophagogastroscopy showing
bleeding ulcer
Gastric erosion Suggested by: history of NSAIDs or alcohol ingestion,
epigastric pain, dull or burning discomfort, nocturnal
pain
Confirmed by: appearance of erosion on
esophagogastroscopy and pH study showing
hyperacidity
Gastric ulcer Suggested by: epigastric pain, dull or burning
discomfort, nocturnal pain
Confirmed by: appearance of ulcer on
esophagogastroscopy and pH study showing
hyperacidity
Mallory–Weiss
tear
Suggested by: preceding marked vomiting, later bright
red blood
Confirmed by: esophagogastroscopy showing tear
Gastroesophageal
reflux
Suggested by: heartburn worse when lying flat,
anorexia, nausea, ± regurgitation of gastric content
Confirmed by: appearance of erosion on
esophagoscopy, barium meal and pH study showing
hyperacidity
Hiatus hernia Suggested by: heartburn, worse with stooping,
relieved by antacids
Confirmed by: herniation of stomach into chest on
plain (X-ray or barium meal), appearance of erosion
on esophagoscopy and pH study showing
hyperacidity
HEMATEMESIS ± MELENA1
243
False
hematemesis
Suggested by: swallowed nose bleed or hemoptysis
Confirmed by: normal esophagogastroscopy and
bleeding source identified in nose
Esophageal
carcinoma
Suggested by: progressive dysphagia with solids, which
sticks, weight loss
Confirmed by: barium swallow, fiber-optic gastroscopy
with mucosal biopsy showing malignant tissue
Gastric
carcinoma
Suggested by: marked anorexia, fullness, pain,
Troisier’s sign (enlarged left supraclavicular lymph
[Virchow’s] node)
Confirmed by: esophagogastroscopy with biopsy
showing malignant tissue
Ingestion of
corrosives
Suggested by: history of ingestion
Confirmed by: esophagogastroscopy showing severe
erosions
Esophageal
varices
Suggested by: liver cirrhosis, splenomegaly, prominent
upper abdominal veins
Confirmed by: esophagogastroscopy showing varicose
mucosa and blood distally and in stomach
Meckel’s
diverticulum
Suggested by: no hematemesis, usually asymptomatic,
anemia, rectal bleeding
Confirmed by: technetium-labeled red blood cell scan,
showing isotopes in gut lumen and laparotomy
Other causes:
angiodysplasia,
bleeding
disorders
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CHAPTER 10 GI symptoms
244
Passage of blood per rectum
(hematochezia)
This may only be discovered on rectal examination.
Some differential diagnoses and typical outline evidence
Bleeding
hemorrhoids
Suggested by: pain, discharge, pruritus, staining of toilet
paper following defecation
Confirmed by: physical and digital rectal examination,
proctoscopy
Anal fissure Suggested by: skin tag, pain on defecation, staining of
toilet paper following defecation, exquisite anal
tenderness
Confirmed by: history and clinical examination
Diverticulitis Suggested by: bloody splash in the pan, abdominal pain,
usually LIF, diarrhea and constipation
Confirmed by: colonoscopy, barium enema
Carcinoma
rectum
Suggested by: rectal bleeding with defecation
Confirmed by: sigmoidoscopy with biopsy
Colonic
carcinoma
Suggested by: red blood mixed with stool and
alternate diarrhea and constipation
Confirmed by: flexible colonoscopy with biopsy
Ulcerative
colitis
Suggested by: lower abdominal pain, i urgency to
defecate, severe bloody diarrhea, i fever in acute
attack.
Confirmed by: colonoscopy with biopsy, barium studies
show loss of haustration, mucosal edema, ulceration
Meckel’s
diverticulum
Suggested by: usually asymptomatic, anemia, rectal
bleeding
Confirmed by: technetium-labeled red blood cell scan,
laparotomy
PASSAGE OF BLOOD PER RECTUM (HEMATOCHEZIA)1
245
Crohn’s disease Suggested by: chronic diarrhea with abdominal pain,
weight loss, palpable RLQ mass or fullness, mouth
ulcers
Confirmed by: colonoscopy with biopsy, barium studies
show “skip lesions,” string sign in advanced cases
Massive upper
GI bleed
Suggested by: bright or dark red, maroon-colored stool
Confirmed by: upper
GI endoscopy
Trauma
(in children,
possible non-
accidental injury)
Suggested by: fresh blood, sometimes external signs of
trauma.
Confirmed by: sensitive and careful history, possible
surveillance etc.
Intussusception Suggested by: child in first 6–18 months of life, acute
onset of colicky intermittent abdominal pain, red
currant “jelly”
PR bleed, ± a sausage shape mass in
upper abdomen
Confirmed by: barium enema, ±reduction of
intussusception with appropriate hydrostatic pressure
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CHAPTER 10 GI symptoms
246
Tenesmus
In tenesmus there is the sensation of needing to defecate, but no stool is
produced.
Some differential diagnoses and typical outline evidence
Rectal
inflammation
(proctitis)
Suggested by: rectal bleeding, mucus discharge
Confirmed by: proctoscopy or sigmoidoscopy reveals
inflamed rectal mucosa
Rectal tumor Suggested by: rectal bleeding with defecation, blood
limited to surface of stool
Confirmed by: sigmoidoscopy with rectal biopsy
Tumor of
descending
colon
Suggested by: alternate diarrhea and constipation
Confirmed by: colonoscopy with biopsy, barium enema
Pelvic
inflammatory
disease
Suggested by: lower abdominal pain, fever, vaginal
discharge, dysuria, elevated ESR and CRP, leukocytosis
Confirmed by: high vaginal swab, pelvic ultrasound, ±
laparoscopy
ANORECTAL PAIN1
247
Anorectal pain
Some differential diagnoses and typical outline evidence
Anal fissure Suggested by: skin tag, pain on defecation, staining of
toilet paper following defecation
Confirmed by: physical zexamination of anal region
Hemorrhoids Suggested by: rectal bleeding following defecation,
perianal protrusion with pain
Confirmed by: digital rectal examination
Perianal abscess Suggested by: tender lump, redness
Confirmed by: digital rectal examination
Proctitis Suggested by: rectal bleeding, mucus discharge
Confirmed by: proctoscopy or sigmoidoscopy revealing
inflamed rectal mucosa
Prostatitis Suggested by: rigor, i fever, urinary frequency and
urgency, dysuria, hemospermia
Confirmed by: tender prostate gland on rectal
examination, urine microscopy
Proctalgia fugax,
coccydynia
Suggested by: fleeting pain in rectum or coccyx that
may be related to sitting, but not defecation
Confirmed by: physical examination, tenderness of
levator muscle
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Chapter 11
249
GI signs
General examination checklist 250
Distended abdomen 251
Distended abdominal veins 252
Abdominal bruising 253
Poor abdominal movement 254
Localized tenderness—
in the hypogastrium (suprapubic area) 255
in the right upper quadrant (RUQ) 256
in the left upper quadrant (LUQ) 257
in the epigastrium or central abdomen 258
in the left or right loin 259
in left or right lower quadrant 260
Hepatomegaly
—smooth and tender 261
—smooth but not tender 262
—irregular, not tender 263
Splenomegaly
—slight (<3 fingers) 264
—moderate (3–5 fingers) 265
—massive (>5 fingers) 266
Bilateral masses in upper abdomen 267
Unilateral mass in right or left upper quadrant 268
Mass in epigastrium (±umbilical area) 269
Mass in right lower quadrant (RLQ) 270
Mass in hypogastrium (suprapubic region) 271
Mass in left lower quadrant (LLQ) 272
Central dullness, resonance in flank 273
Shifting dullness 274
Silent abdomen with no bowel sounds 275
High-pitched bowel sounds 276
Abdominal or groin bruit 277
Lump in the groin 278
Anal appearance 279
Melena on finger 280
Fresh blood on finger on rectal examination 282
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CHAPTER 11 GI signs
250
General examination checklist
Preliminary findings should have been discovered during the general
examination. These include jaundice, anemia, clubbing, xanthelasma, or
gynecomastia; abnormalities of the lips, buccal mucosa, throat, and tongue;
the presence of supraclavicular lump(s).
DISTENDED ABDOMEN1
251
Distended abdomen
Inspect the abdomen from a sitting position next to the bed or couch.
Consider the general shape, then look at the skin. Next, consider move-
ment of the abdomen. The causes are the traditional 6 F’s: Fat, Fluid,
Flatus, Feces, Fibroids, and Fetus.
Some differential diagnoses and typical outline evidence
Fat (obese) Suggested by: usually sunken umbilicus, dullness to
percussion throughout
Confirmed by: CT abdomen
Fluid (ascites) Suggested by: bilateral bulging flanks, shifting dullness,
fluid thrill
Confirmed by: ultrasound liver and abdomen
Flatus (gas)
due to normal
dietary variation
Suggested by: tympanic sound throughout. Often
associated with constipation
Confirmed by: AXR
shows normal gas shadow
Small bowel
obstruction
(“flatus” again)
Suggested by: mild distension, early vomiting, central
and high abdominal pain, resonant percussion, and
increased bowel sounds. Supine AXR showing central
gas but no peripheral abdominal large-bowel shadow
(i.e., without haustra partly crossing) but valvulae
conniventes of small intestine entirely crossing the
lumen. Fluid levels on erect film
Confirmed by: abdominal ultrasound and laparotomy
findings
Large bowel
obstruction
Suggested by: severe distension, late vomiting, visible
peristalsis, resonant percussion, and increased bowel
sounds. Supine AXR showing peripheral abdominal
large-bowel shadow (with haustra partly crossing the
lumen). Fluid levels on erect film
Confirmed by: abdominal ultrasound and laparotomy
findings
Fecal
i
ii
impaction
Suggested by: paucity of bowel movement and
constipation. AXR shows stippled pattern of fecal
loading
Confirmed by: digital exam, resolution of distension
with evacuation
Fibroids, large
ovarian cyst
Suggested by: mass in pelvis in middle-aged female
Confirmed by: abdominal ultrasound
Fetus Suggested by: amenorrhea and mass in pelvis (cannot
get below it)
Confirmed by: positive urine pregnancy test or iplasma
β
-hCG. Also abdominal ultrasound
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