For the fresh undergraduate

1. Symptomatology
of
Gastrointestinal
System
III Term
Dept of Medicine
ACMS

2. Learning Objectives
• Learn definitions and meanings of common
terms associated with gastrointestinal symptoms
• Learn to localize disease from symptoms

3. Gastrointestinal Symptoms
• Most common presenting complaints in OPD
setting
• Great overlap of symptoms in GI Disorders
• Overlap with other systems and sites
• Severity does not correlate well with
seriousness of disease

4. Divisions
• Upper GI-Above DJ Flexure

5. Divisions
• Upper GI
• Middle GI-
Uptil Ileoceacal Junction

6. Divisions
• Upper GI
• Middle GI
• Lower GI- Upto anal verge

7. Divisions
• Upper GI
• Middle GI
• Lower GI
• Liver and Biliary Tract

8. Divisions
• Upper GI
• Middle GI
• Lower GI
• Liver and Biliary Tract
• Pancreas

9. Divisions
• Upper GI
• Middle GI
• Lower GI
• Liver and Biliary Tract
• Pancreas
Considerable overlap of
symptoms

10. Upper GI Symptoms

11. Upper GI Symptoms
• Dysphagia and Odynophagia-

12. Upper GI Symptoms
• Dysphagia and Odynophagia- Difficulty and
pain in swallowing

13. Upper GI Symptoms
• Dysphagia and Odynophagia- Difficulty and
pain in swallowing
• Esophagitis
• Achalasia – motility disturbance
• Stricture
• Carcinoma

14. Upper GI Symptoms
• Heartburn, Regurgitation &Reflux (eructation)-

15. Upper GI Symptoms
• Heartburn, Regurgitation &Reflux (eructation)-
• GERD-Reflux Esophagitis
• Gastritis
• Peptic Ulcer Disease

16. Upper GI Symptoms
• Dyspepsia –

17. Upper GI Symptoms
• Dyspepsia - Combination of Indigestion, pain,
distention, acidity, nausea (and Hunger Pains)

18. Upper GI Symptoms
• Dyspepsia - Combination of Indigestion, pain,
distention, acidity, nausea (and Hunger Pains)
• Gastroduodenitis
• Chronic Pancreatitis
• Chronic Cholecystitis
• Hepatitis
• Carcinoma Stomach and Pancreas

19. Upper GI Symptoms
• Flatulence

20. Upper GI Symptoms
• Flatulence (Burping, Belching, Flatus)

21. Upper GI Symptoms
• Flatulence (Burping, Belching, Flatus)
• Chronic Pancreatitis
• Gastroduodenitis
• Anxiety
• Food Intolerance

22. Upper GI Symptoms
• Anorexia-

23. Upper GI Symptoms
• Anorexia- Reduced appetite

24. Upper GI Symptoms
• Anorexia- Reduced appetite
• Hepatitis
• Gastroduodenitis
• Gastroenteritis
• Carcinoma

25. Upper GI Symptoms
• Nausea, Retching &Vomiting

26. Upper GI Symptoms
• Nausea, Retching &Vomiting
• Gastroduodenitis, Gastroenteritis
• Hepatitis, Pancreatitis, Cholecystitis
• Pyloric Obstruction, Carcinoma

27. Upper GI Symptoms
• Hematemesis-

28. Upper GI Symptoms
• Hematemesis- Blood in Vomit

29. Upper GI Symptoms
• Hematemesis- Blood in Vomit
• Esophageal Varices
• Acute Gastritis
• Peptic Ulcer
• Gastric cancer

30. Upper GI Symptoms
• Hematemesis- Blood in Vomit
• Esophageal Varices
• Acute Gastritis
• Peptic Ulcer
• Gastric cancer
• Melaena-

31. Upper GI Symptoms
• Hematemesis- Blood in Vomit
• Esophageal Varices
• Acute Gastritis
• Peptic Ulcer
• Gastric cancer
• Melaena- Digested blood passed in stool

32. Upper GI Symptoms
• Dysphagia and Odynophagia
• Heartburn and Reflux (eructation)
• Dyspepsia and Hunger Pains
• Flatulence (Burping, Belching, Flatus)
• Anorexia
• Nausea, Retching &Vomiting
• Hematemesis and Maelena

33. Lower GI Diseases

34. Lower GI Diseases
• Enteritis/ Ileitis
• Meckel's Diverticulitis
• Diverticulitis
• Crohn’s Disease
• Colitis (idiopathic,
infectious)
• Colonic polyps
• Carcinoma
• Hemorrhoids
• Fissure
• Irritable bowel
syndrome
• Ischemic colitis
• Radiation colitis
• Omental torsion
• Mesenteric
lymphadenitis

35. Lower GI Symptoms

36. Lower GI Symptoms
• Constipation-

37. Lower GI Symptoms
• Constipation- Less than 3 stools/ week. Hard,
pellet like and difficult to pass

38. Lower GI Symptoms
• Diarrhea, Dysentery & Spurious Diarrhea

39. Lower GI Symptoms
• Diarrhea, Dysentery & Spurious Diarrhea
• > 200 -300 gm /day
• >3 times / day- liquid consistency
• Mucous and Blood

40. Lower GI Symptoms
• Tenismus-

41. Lower GI Symptoms
• Tenismus- Sense of incomplete evacuation

42. Lower GI Symptoms
• Alteration of Bowel Pattern

43. Lower GI Symptoms
• Proctalgia:

44. Lower GI Symptoms
• Proctalgia: Painful Defecation

45. Lower GI Symptoms
• Rectal Bleeding

46. Lower GI Symptoms
• Hematochezia

47. General Symptoms
• Pain
• Distention & Swelling
• Weight Loss
• Fever
• Malnutrition and Hypovitaminosis

48. Abdominal Pain: Pathophysiology
• Three classes of abdominal pain

49. Abdominal Pain: Pathophysiology
• Three classes of abdominal pain
1) Visceral

50. Abdominal Pain: Pathophysiology
• Three classes of abdominal pain
1) Visceral
2) Somatic

51. Abdominal Pain: Pathophysiology
• Three classes of abdominal pain
1) Visceral
2) Somatic
3) Referred

52. Abdominal Pain: Pathophysiology
• Three classes of abdominal pain
1) Visceral
2) Somatic
3) Referred

53. Visceral Pain
Originates in-
• the walls of hollow organs
• the capsules of solid organs
• the visceral peritoneum

54. Visceral Pain
Originates in-
• the walls of hollow organs
• the capsules of solid organs
• the visceral peritoneum
Three separate mechanisms can produce this
pain:

55. Visceral Pain
Originates in-
• the walls of hollow organs
• the capsules of solid organs
• the visceral peritoneum
Three separate mechanisms can produce this
pain:
1) Inflammation
2) Distention (being stretched out or inflated)
3) Ischemia (inadequate blood flow)

56. Visceral Pain
• All viscera transmit a pain signal from visceral
afferent neural fibers back to the spinal
column

57. Visceral Pain
• All viscera transmit a pain signal from visceral
afferent neural fibers back to the spinal
column
• Pain is usually not localized to any one specific
area
• Described as very vague or poorly localized,
dull or crampy

58. Visceral Pain
• All viscera transmit a pain signal from visceral
afferent neural fibers back to the spinal
column
• Pain is usually not localized to any one specific
area
• Described as very vague or poorly localized,
dull or crampy
• Body responds through parasympathetic
stimulation causing Nausea/Vomiting,
Diaphoresis and Bradycardia

59. Somatic Pain

60. Somatic Pain
• Sharp pain that travels along definite neural
routes (dermatomes) to the spinal cord

61. Somatic Pain
• Sharp pain that travels along definite neural
routes (dermatomes) to the spinal cord
Usually associated with-

62. Somatic Pain
• Sharp pain that travels along definite neural routes
(dermatomes) to the spinal cord
Usually associated with-
Perforations or ruptures of hollow organs- Peritonitis
– bacterial (ruptured appendix or gall bladder)
– chemical (perforated ulcer or inflamed pancreas)
Abdominal wall lesions-
– Contusion
– Hematoma
– Tumor

64. Referred Pain

65. Referred Pain
• Originates in a region other than where it is felt

66. Referred Pain
• Originates in a region other than where it is felt.
• Many neural pathways from various organs pass
through regions where the organ was formed
during embryonic development.

67. Referred Pain
• Originates in a region other than where it is felt.
• Many neural pathways from various organs pass
through regions where the organ was formed
during embryonic development.
• Examples:
1. Inflammation of diaphragm causes referred
pain in neck or shoulder

68. Referred Pain
• Originates in a region other than where it is felt.
• Many neural pathways from various organs pass
through regions where the organ was formed
during embryonic development.
• Examples:
1. Inflammation of diaphragm causes referred
pain in neck or shoulder
2. Dissecting abdominal aortic aneurysm
produces referred pain between shoulder
blades

69. History of Pain Abdomen
OPQRST-ASPN

70. History of Pain Abdomen
OPQRST-ASPN
1. Onset: when did the pain start,
was it sudden or gradual?

71. History of Pain Abdomen
OPQRST-ASPN
1. Onset: when did the pain start,
was it sudden or gradual?
2. Provocation/Palliation: makes
the pain worse or better?

72. History of Pain Abdomen
OPQRST-ASPN
1. Onset: when did the pain start,
was it sudden or gradual?
2. Provocation/Palliation: makes
the pain worse or better?
3. Quality: dull, sharp, constant?

73. History of Pain Abdomen
OPQRST-ASPN
1. Onset: when did the pain start,
was it sudden or gradual?
2. Provocation/Palliation: makes
the pain worse or better?
3. Quality: dull, sharp, constant?
4. Region/radiation: pain travel?

74. History of Pain Abdomen
OPQRST-ASPN
1. Onset: when did the pain start,
was it sudden or gradual?
2. Provocation/Palliation: makes
the pain worse or better?
3. Quality: dull, sharp, constant?
4. Region/radiation: pain travel?
5. Severity: scale 1-10

75. History of Pain Abdomen
OPQRST-ASPN
1. Onset: when did the pain start,
was it sudden or gradual?
2. Provocation/Palliation: makes
the pain worse or better?
3. Quality: dull, sharp, constant?
4. Region/radiation: pain travel?
5. Severity: scale 1-10
6. Time: when and how long?

76. History of Pain Abdomen
OPQRST-ASPN
1. Onset: when did the pain start,
was it sudden or gradual?
2. Provocation/Palliation: makes
the pain worse or better?
3. Quality: dull, sharp, constant?
4. Region/radiation: pain travel?
5. Severity: scale 1-10
6. Time: when and how long?
7. Associated Symptoms

77. History of Pain Abdomen
OPQRST-ASPN
1. Onset: when did the pain start,
was it sudden or gradual?
2. Provocation/Palliation: makes
the pain worse or better?
3. Quality: dull, sharp, constant?
4. Region/radiation: pain travel?
5. Severity: scale 1-10
6. Time: when and how long?
7. Associated Symptoms
8. Pertinent Negatives

78. Abdominal Distention
Fluid Gaseous

79. Abdominal Distention
Fluid
• Ascites
• Peritonitis
• Perforations
• Abscess
• Hemorrhage
Gaseous

80. Abdominal Distention
Fluid
• Ascites
• Peritonitis
• Perforations
• Abscess
• Hemorrhage
Gaseous
• Ileitis and Colitis
• Intestinal Obstruction
• Adhesions
• Intusseption
• Volvulus
• Messenteric ischemia

81. Ascites and Malnutrition

82. Malnutrition
• Macronutrients & Micronutrients

83. Malnutrition
• Macronutrients & Micronutrients
• Malabsorbtion & maldigestion

84. Hypovitaminosis

85. Liver & Biliary Tract
• Acute Hepatitis
• Chronic Hepatitis
• Cirrhosis
• Cholecystitis
• Cholelithiasis
• Hepatocellular
Carcinoma
• Gall Bladder Cancer

86. Symptoms of Liver & Biliary Tract
• Jaundice

87. Icterus

88. High Colored Urine

89. Liver & Biliary Tract
• Jaundice
• Itching

90. Pruritus

91. Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia, nausea, vomiting – as for Upper GI

92. Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia nausea vomiting
• Pain – Visceral, Somatic, Referred

93. Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia nausea vomiting
• Pain
• Fever- Infections and Malignancy

94. Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia nausea vomiting
• Pain
• Fever
• Bleeding manifestations- Coagulation Factors,
Hypersplenism, DIC

95. Subconjunctival Hemorrhage

96. Ecchymoses

97. Petechiae

98. Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia nausea vomiting
• Pain
• Fever
• Bleeding manifestations
• Fluid Distention-Ascites, Peritonitis,
Hemoperitoneum

99. Fluid Distention

100. Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia, nausea, vomiting
• Pain
• Fever
• Bleeding manifestations
• Fluid Distention
• Altered Sensorium- Encephalopathy

101. Altered Sensorium

102. Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia, nausea,
vomiting
• Pain
• Fever
• Bleeding manifestations
• Fluid Distention
• Altered Sensorium
• Lump Abdomen

103. Lump Abdomen- Spleen

104. Gall Bladder Lump

105. Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia nausea
vomiting
• Pain
• Fever
• Bleeding manifestations
• Fluid Distention
• Altered sensorium
• Lump Abdomen
• Breast Enlargement

106. Gynaecomastia- Breast Enlargement

107. Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia nausea
vomiting
• Pain
• Fever
• Bleeding manifestations
• Fluid Distention
• Altered sensorium
• Lump Abdomen
• Breast Enlargement
• Parotid Enlargement

108. Parotid Enlargement

109. Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia nausea
vomiting
• Pain
• Fever
• Bleeding manifestations
• Fluid Distention
• Altered sensorium
• Lump Abdomen
• Breast Enlargement
• Parotid Enlargement
• Spider Angiomata

110. Spider Angiomata

111. Liver & Biliary Tract
• Jaundice
• Itching
• Anorexia, Nausea,
Vomiting
• Pain
• Fever
• Bleeding manifestations
• Fluid Distention
• Altered Sensorium
• Lump Abdomen
• Breast Enlargement
• Parotid Enlargement
• Spider Angiomata
• Dupuytren’s Contracture

112. Dupuytren’s Contracture

113. Symptoms of Acute Pancreatic Disorders
• Fever
• Pain- excruciating, continuous
• Vomiting- no relief in pain
• Distention- gaseous and fluid
• Jaundice- variable

114. Symptoms of Chronic Pancreatic Disorders
• Anorexia
• Dyspepsia
• Diarrhea
• Steatorrhea
• Malnutrition
• Diabetes

115. Case 1: 22 year old foreign tourist, had
street food in Sarojini Nagar last night
• Fever with chills
• Colicky pain abdomen
• Nausea &vomiting 4 times
• Profuse watery diarrhea 8 times
All for 8 hours

116. Case 2: 40 Year old housewife
Having Dyspepsia off and on for 1 year
• Fever
• Pain Upper Abdomen
• Vomiting and retching
• Yellow discoloration of urine
All for 2 days
• Pale stools this morning

117. Case 3: 50 Year old Alcoholic X 30 Years
• Recurrent pain abdomen and dyspepsia after
alcohol X 2 years
• Jaundice 1 year ago
• Lump in abdomen since 1 year
• Fresh Blood in vomiting 6 months ago
• Vomiting & painful abdominal distention X 3 D
• Fever X 2 days

118. 25 year old lady on antidepressants X 1 month
• Hard stools X 3 weeks
• Painful defecation X 1 week
• Bleeding after passage of stool X 1 day

119. 40 year old businessman
• Constipation X 1 month
• Intermittent large watery stool after initial
passage of hard motion every 3 to 4 days
• Weight loss of 3 Kgs in last month
• Blood in stool yesterday

120. 55 year old obese, smoker and alcoholic
Taking Antacids for Heartburn and Dyspepsia for
several years
• Difficulty in swallowing solids X 1 month
• Vomiting of undigested food X 3 weeks
• Difficulty in swallowing liquids X 1 week
• Weight loss of 8 Kgs in 2 months

121. 40 year old teacher
• Pain & stiffness in small &large joints X 2 M.
Recently diagnosed as Rheumatoid Arthritis
Prescribed multiple medications
• Dyspepsia and pain abdomen X 1 week
• Tarry stools X 2 days
• Dark coffee colored vomiting this morning

122. Sep 09. 25 Yr old soldier, a case of GERD on H2
Blockers. Returned from village 2 weeks ago.
Admitted in Med I X 1 week
• Fever X 10 Days- high grade for 1 week
• Pain abdomen X 8 Days – continuous and diffuse. Severe
X 2 days
• Initial mild diarrhea X 2 -3 days
• Constipation X 1 week
• Vomiting and abdominal distention X 1 day
• Not passed flatus/ faeces today
• No jaundice, Hematemesis, Melaena

123. Sep 09. 25 Yr old soldier, a case of
GERD on H2 Blockers.
• Had received
• Amoxycillin 1.5 gm per day X 3 Days
• Ciproflox 250 mg 3 times a day X 3 Days
• From Pvt practitioner

124. General Examination
• Slim built. Looks ill and toxic today.
• T 40 degree C, Pulse 90/min low volume,
• BP 80/ 40 mm Hg, Respiration 28/ min
• Dehydration +, Pallor +, Tinge of Icterus +
• Rose spots-Blanching maculo-papular rash over
trunk + (fair skinned individual).
• Mutteing incoherently & picking at bed clothes-
Delerium +
• No lymphadenopathy, arthritis, petechiae or
purpura

125. Abdominal Examination
• Diffuse tenderness, guarding and distention
• No rigidity.
• Girth has increased by 3 cms
• No free fluid, only gaseous distention
• Liver palpable 2 cm, soft and tender
• Spleen 1 cm, soft and tender
• No other mass
• Bowel sounds feeble

126. Other Systemic Examination
• CNS: Delerium +, No focal neurological signs,
No signs of meningeal irritation
• Respiratory System: Dry mild cough noted.
Lungs Clear
• CVS: Heart sounds normal.

127. Investigations
• Hb- 11 gm/dl
• TLC-3200/cc
• DLC -N 15%, L 75%, M 10%
• Platelets- 80,000/cc
• PT/INR – slightly prolonged
• LFT: Bilirubin 2.6 mg/dl, OT 160, PT 220 IU/l
• Urea 40 mg/dl, Creatinine 1.8 mg/dl
• Blood Glucose: 70 mg/dl
• Electrolytes: K+ less

128. Investigations contd..
• Widal (Paired Sera 1 week apart)
• TO 1: 160 1: 320
• TH 1: 320 1: 640
• AH < 1:80
• BH <1: 80
• Blood Culture after 72 hrs- Non Lactose Fermenter
grown _____________________, ABST available

129. Take Home Messages
• GI Symptoms are the most common presenting
complaints in OPD setting
• Great overlap of symptoms in GI Disorders
• Overlap with other systems and sites
• Severity does not correlate well with seriousness
of disease
• Hematemesis and maelena are upper GI
symptoms
• Bleeding in the lower GI presents as bleeding PR
and Haematochesia