SOMATIC PAIN

Blood between the rectus sheath.  Dark Blood, so not fresh, prob a day or two old.  Can lose a lot of blood in there...esp if have low platelets, on clot inhibitors etc.

It will be focal and tender, and they will point to it. (not hurt on the other side)

Biliary Colic Referred to directly below the right scapula

Perforated Duodenal Ulcer or Ruptured Spleen...irritates diaphragm...innervation referred pain...over trapezuis area

Acute Pancreatitis and Renal Colic refer to back because they are retroperitoneal

Uterine and Rectal Pain refer to sacrum

Large Bowel Pain lower than small bowel pain

Renal Colic refer to ipsilateral groin or testicle depending on if you are Male or Not

Usually appendicular colic pretty much dead on midline

OBTURATOR SIGN

-Detects inflammation overlying Obturator Internus muscle (ie RETROPERITONEAL APPENDICITIS)

-Actually done in Musculoskeletal Exam

-Patient will say "ow, that hurts"

PSOAS SIGN

-Detects Inflammation of overlying ILIOPSOAS MUSCLE (ie RETROPERITONEAL APPENDICITIS)

-PT extending leg, and you passively pull it back, stretching the psoas fascia.  There is another way to do it as well.

PERFORATED DOUDENAL ULCER (free intraperitoneal air)

A: Diaphragm

B:Free Air (can see on left side as well, but above that extra bubble which is actually air in the STOMACH)

C: LIver

-Much easier to see on the right, because don't have to sort out if that is due to the normal stomach bubble or not.  SHould NEVER see any air on right. 

-To see air Post surgery a few days, not a big deal.  If NOT had surgery, they need to go to O.R, they have perforated.

EXAM: RUQ TYMPANY!!!! (RUQ tympany is NOT better than X-ray, but can be helpful if can't get X ray or as adjunct.)

VASCULAR DISEASE AFFECTING THE ABDOMEN

1) Small bowel Ischemia

2) Cholesterol Embolization

3) Aortic Aneurysm

THIS PICTURE

This is the picture of the aortic disection, and where you might catch the Celiac Artery, the SMA, the IMA, and they may get bowel ischemia and abdomial pain from that.  That may be the presenting symptom.

SMALL BOWEL ISCHEMIA

IMAGES

1) NORMAL: Angiogram showing descding Aorta.

2) A: Celiac, SMA, and IMA arteries occluded by CLot

RISK FACTORS FOR SMALL BOWEL ISCHEMIA
1) Atherosclerosis

2) Arrythmia (esp Afib)

3) Age >65 years

4) Low Cardiac Output (CHF)

5) Valvular Disease (esp those who develop vegetations)

6) Hypercoaguable States

SMALL BOWEL ISCHEMIA SYNDROMES

1) ACUTE ARTERIAL ISCHEMIA (50-60%)

-Most common

-Mortality 60%

-Acute Abdominal Pain out of proportion to exam tenderness

2) CHRONIC ARTERIAL ISCHEMIA

-Post Prandial Pain (intestinal angina)

-The pt has a fixed stenosis (similar to severe Angina Pectoris).  When eat meal, need blood to gut.  If so fixed and cannot do that, get tons of pain to their gut.  Very hard to diagnose.  Need to take great history, have high index of suspicion, etc.  Typically wil be losing weight, pain when eat, etc.

3) MESENTERIC VEIN THROMBOSIS (5-15%)

-Insidious Abdominal Pain evolving over 7-10 days

-Like DVT of the gut.  Pain is not as sudden as onset as arterial occlusion, which is why the dx is often missed.  Have to dx by THINKING about it, and by doing contrast enhanced scan of the abdomen.

**HAVE TO MAKE THESE DX'S QUICK, BECAUSE GUT CAN DIE VERY QUICKLY

-IF the organ is acutely ischemic you only have hours to work, so need to make this dx quickly.  If wait to see ALL the signs, they will likely have infarcted their bowel, and they may be dead.

CHOLESTEROL EMBOLIZATION (ATHEROEMBOLISM)

1) Caused by rupture of Atheromatous Plaques, often after vascular procedure

CLINICAL SYNDROMES

-Blue Toes

-Renal Failure

-Mesenteric Ischemia

EXAM FINDINGS

-Livedo Reticularis

-Blue Toes

-Evidence of Vascular Disease

-Hollenhorst Crystals

MELANIC STOOL

1) Black AND Tarry Stool

2) Reflects Digested Blood(so needs to be from a somewhat high origin, like Upper GI Bleed PROXIMAL to ligament of TRIETZ)

3) (60cc required)

4) Needs to be BLACK AND TARRY (not just Black, because IRON AND BISMUTH (Peptobismol) may darken stools (Not Tarry)

AORTO-ENTERIC FISTULA (A RARE CAUSE OF UGI BLEEDING)

-Aortic aneruysm had grown so big, and had pushed into doudenum.  Doudenum is stuck to it.  And as it leaks/erodes into doudenum, It leaks into doudenum...GI BLEED.  If they bleed that time, that is your chance to save a life, because they don't bleed out out of their gut.

Have to get CT which can only be suggestive.  If suspect this, need to do surgery.

The KEY is hx of aortic aneursym, esp repaired aneurysm. Old time repair, end to end, was VERY close to doudenum, and risk that it could leak at suture line.  Now these are done internally, with a smaller risk of leaking at the suture line.

**ARROW SAYING THAT 75% INVOLVE DISTAL DOUDENUM

OSLER-WEBER-RENDU SYNDROME

1) Multisystem Disorder

2) TELANGECTASIAS OF LIP AND TONGUE IS ARROW

3) Abnormal vascular channels throughout the body
4) Usually not BIG time GI bleeding, becayse these are throughout GI tract and are just bleeding a little bit.

5) Guiac + Stoll and Iron deficiency anemia is usually what they have.

JAUNDICE: SCLERAL ICTERUS

PANCREAS, DOUDENUM, AND EXTRAHEPATIC BILE DUCTS

1) Bile is concentrated in GB. You can cut that off (#5) and you are not Jaundice.  Get obstruction of Cystic duct leaving GB and get Biliary Colic (#5) and potentially Acute Cholecystitis, but NOT JAUNDICE. 

2) However, if you get obstruction at Ampulla of Vater (#9) or in common BIle Duct (#6), you can get Jaundice

3) In PBC, the blockage is within the liver parnchyma itself (throughout #25)

DETECTING ASCITES: Shifting Dullness is the better method

1) The rotate person, and re-establish where changes from tympanic to dullness, and if that line changes, it is shifting dullness.

2) Next best is abdominal US

DETECTING SPLENIC ENLARGEMENT

Take right hand, pull underneath pt, have pt take deep breath.  If tender, they will NOT take deep breath, they will splint, and you will not be able to see it.

As spleen enlarges, it will go down midline.  Can go very low, so have to START very low.  What you are really looking for is the TIP.

SPLENOMEGALY DETECTION

1) And asking pt to slowly take a deep breath, and feeling for the spleen tip to come into contact with your hand.

2) Mild Enlargement: Sensitivity=56%; Specificity 69%

3) EXTREME Enlargement: Sensitivity: 97% (The bigger the spleen, the more sensitive it is.)

4) With RIGHT SIDE DOWN...Have pt roll on right side and sort of push Spleen anterior towards you.

DILATED ABDOMINAL WALL VEINS

1) Anastamotic Channels to systemic circulation.

2) TO diagnose Portal Hypertension...

 a. Sensitivity: 42%

 b. Specificty: 98%

MORE (VERY) SPECIFIC THAN SENSITIVE

HEPATOMEGALY

1) These numbers are the NORMAL SIZES

2) When FEELING for Hepatomegaly as a TEST (versus imaging estimate of Liver Size in Jaundice Pts)...

 a. Sensitivity: 71-83%

 b. Specificty: 15-17%

3) ENLARGED LIVER MAY BE DUE TO...

 a. Hepatitis

 b. Passive Congestions

 c. Cancer

 d. Cirrhosis (may also be small)

 e. Hepatic Vein Thrombosis (Budd Chiari Syndrome.   Same Pathogenesis as R. Heart Failure.  Backup of Flow, and will have a Tender Liver.)

4) CIRRHOTIC LIVERS ARE NOT TENDER

 a. Except in cirrhosis via Right Heart Failure

 b. Except in Chronic Cirrhosis

Portosystemic Venous Connections

(sup. rectal veins lead to internal hemmorhoids)

ESOPHOGEAL VARICIES

The large columns are from large venous structures.  Tried to cauterize them with a probe, but did not work.

GYNECOMASTIA in CIRRHOSIS

1) Estrogen Effect

2) Not just fat, it is actually breast ductal tissue.  It is not just fat, it is breast tissue growing in a man.

PALMAR ERYTHEMA in CIRRHOSIS

1) possibly due to EStrogen Effect

2) Vascular Dilation...esp Hypothenar eminence

SPIDER ANGIOMAS IN CIRRHOSIS

1) Estrogen Effect

2) They BLANCH because they have a central feeding vessel.

ASTERIXIS: Metabolic Encephalopathy (due to change in Amino Acid Profile)

1) it is NOT a tremor. 

2) It is intermittent loss of extensor Tone

3) Have them hold out hands like saying stop, and over time they will lose their extensor tone, fall down, and try to recover, may look like a flap.

4) Not specific to liver disease.  Can see with other Encephalopathies, and Renal Failure.  Thought to be problem with Brain NT's that liver not metabolizing correctly.

Hepatitis C: mixed cryoglobulinemia

1) 'A" is GROSS ASCITES WITH CAPUT MEDUSA

2) Mixed Cryoglobulinemia is a SMALL VESSEL VASCULITIS caused by POLYCLONAL IMMUNE COMPLEXES DEPOSITING IN TISSUES (Immune Complex Disease)

3) Depending on Study, an uncommon-to-rare event complicating Hepatitis C

STEATORRHEIC STOOL

This stool is VERY malodorous.
It is STICKY
It FLOATS
is DIFFICULT TO FLUSH

These are what you ask about Steatorrhea

ATROPHIC GLOSSITIS (TONGUE PART OF GI)

*THESE IMAGES ARE CT SCAN and VIRTUAL COLONSCOPY SHOWING APPLE CORE LESION. OF COLONIC CARCINOMA

WHEN A PATIENT PRESENTS WITH THE FOLLOWING CONCERNING COMPLAINTS ALONG WITH CONSTIPATION, you should think COLOINC CARCINOMA:

1) Blood Per Rectum

2) Reduced Stool Caliber (Distal Colonic or Rectal Growth...Pencil Thin Stools)

3) Weight Loss

4) Iron Deficiency Anemia (not a complaint, per se) (Esp in Man, or Non-menstruaing woman.  Not as abnormal in menstruating woman)

**WANT TO RULE OUT THE REALLY BAD THING: NEOPLASIAS CAUSING CONSTIPATION.

COMPLICATIONS OF GERD

1) That pink endoscopic view...SMALL AND FIXED=ABNORMAL

2) ADENOCARCINOMA OF ESOPHAGUS AS COMPLICATION OF LONG STANDING GERD
3) THESE PTS NEED TO BE FOLLOWED CLOSELY BY A GASTROENTEROLOGIST

ACHALASIA

A) Dilated Esophagus (Contrast Filled)

B) Closed LES

Squamous Carcinoma of Esophagus (Barium image)

A) Narrowed Esopheal Lumen

B) MASS

Squamous Carcinoma of Esophagus (ENDOSCOPY)

C) EXOPHITIC MASS

RETROPERITONEAL BLEEDING: GREY-TURNER'S SIGN

Sign of retroperitoneal bleeding:

PROGRESSIVE DYSPHAGIA

"I used to be able to eat everything but steak.  Then Pasta.  Now I can only eat yogurt."  BAD.  Progressively the hole is getting smaller.  LIKELY TO BE CANCER.

SOLIDS AND LIQUIDS EQUALLY AFFECTED

Mechanical Problems wouldn't be the same for solids and liquids......more problem with coordination of swallowing, not a fixed occlusion

EPISODIC OVER YEARS: MORE MOTOR

Cancer tends to get worse, and not stay same

PROMINENT WEIGHT LOSS: MORE MECHANICAL EXCEPT ALS

Cancer is main thing you worry about.  But if ALS, will be dominated by ALS sx (weakness, etc)

RECURRENT ASPIRATION: EITHER MOTOR OR MECHAN

Can be either because not swallowing correctly.