Gastroparesis Nausea, vomiting, abdominal pain, early satiety, postprandial fullness, and bloating

Causes of left upper quadrant (LUQ) abdominal pain

LUQ Clinical features

Splenomegaly Pain or discomfort in LUQ, left shoulder pain, and or early satiety

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Splenic infarct Severe LUQ pain

Splenic abscess Associated with fever or LUQ tenderness

Splenic rupture May complain of LUQ, left chest wall, or left shoulder pain that worsens with inspiration

Causes of lower abdominal pain

Lower

abdomen

Localization Clinical features

Appendicitis Generally right lower quadrant Periumbilical pain initially that radiates to the right lower

quadrant. Associated with anorexia, nausea, and vomiting

Diverticulitis Generally left lower quadrant, right lower

quadrant more common in Asian patients

Pain usually constant and present for several days prior to

presentation. May have associated nausea and vomiting

Nephrolithiasis Either Pain most common symptom, varies from mild-to-severe. Generally flank pain but may have back or abdominal pain

Pyelonephritis Either Associated with dysuria, frequency, urgency, hematuria, fever,

chills, flank pain, and costovertebral angle tenderness

Acute urinary

retention

Suprapubic Present with lower abdominal pain and discomfort, inability to

urinate

Cystitis Suprapubic Associated with dysuria, frequency, urgency, and hematuria

Infectious

colitis

Either Diarrhea is the predominant symptom, but may also have

associated abdominal pain which may be severe

Causes of diffuse abdominal pain

Diffuse/poorly characterized Clinical features

Bowel obstruction Most common symptoms are nausea, vomiting, crampy abdominal pain, and

obstipation

Distended tympanic abdomen with high-pitched or absent bowel sounds.

Perforation of the gastrointestinal

tract

Severe abdominal pain, particularly following procedures

Acute mesenteric ischemia Acute and severe onset of diffuse and persistent abdominal pain often described as pain

out of proportion to examination

Chronic mesenteric ischemia Abdominal pain after eating (“intestinal angina”), weight loss, nausea, vomiting, and

diarrhea

Inflammatory bowel disease

(ulcerative colitis/Crohn’s disease)

Associated with bloody diarrhea, urgency, tenesmus, bowel incontinence, weight loss,

and fever

Viral gastroenteritis Diarrhea accompanied by nausea, vomiting, and abdominal pain

Spontaneous bacterial peritonitis Fever, abdominal pain, and/or altered mental status

Dialysis-related peritonitis Abdominal pain and cloudy peritoneal effluent. Other symptoms and signs include fever,

nausea, diarrhea, abdominal tenderness, and rebound tenderness

Colorectal cancer Variable presentation, including obstruction and perforation

Other malignancy Vary depending on malignancy

Celiac disease Abdominal pain in addition to including diarrhea with bulky, foul smelling, floating stools

due to steatorrhea and flatulence

Ketoacidosis Diffuse abdominal pain, nausea and vomiting

Adrenal insufficiency Diffuse abdominal pain, nausea and vomiting

Foodborne illness Mixture of nausea, vomiting, fever, abdominal pain, and diarrhea

Irritable bowel syndrome Chronic abdominal pain with altered bowel habits

Constipation Diffuse abdominal pain

Diverticulosis May have symptoms of abdominal pain and constipation

Lactose intolerance Associated with abdominal pain, bloating, flatulence, and diarrhea. Abdominal pain may

be cramping in nature

NOTES

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D. DISCUSSION ON EXAMINATION

GENERAL EXAMINATION

General Physical Examination in Gastroenterology and Hepatobiliary System

Pulse

Tachycardia—anemia, hypovolemia

Bradycardia—obstructive jaundice

High volume pulse—cirrhosis of liver

Blood pressure

Wide pulse pressure—cirrhosis

Low blood pressure—sepsis, UGI bleed

Fever

SBP

Hepatoma

Cirrhosis

Hepatitis

Abscess

Pancreatitis

Inflammatory bowel disease

Pallor

GI bleed

Anemia of chronic disease

Macrocytic anemia—liver disease, B12 and folate deficiencies

Icterus

Hepatic

Posthepatic

Cyanosis

Hepatopulmonary syndrome

Pleural effusion

Clubbing

Primary biliary cirrhosis

Inflammatory bowel disease

HCC

Lymphadenopathy

Tuberculosis

HIV

Lymphoma

Pedal edema

Cirrhosis

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7.

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Nephrotic syndrome

CKD

Peripheral Signs of Chronic Liver Disease

Skin, nail and hands

Spider nevi (telangiectatic superficial blood vessels with central feeding vessel)

Clubbing of hands (especially biliary cirrhosis and hepatocellular carcinoma)

Leukonychia

Palmar erythema (blotchy appearance over the thenar and hypothenar eminence)

Brusing

Dupuytren’s contracture (sign of alcoholism)

Scratch marks (cholestatic jaundice)

Endocrine—due to estrogen excess

Gynecomastia

Atrophy of testis

Loss of axillary and pubic hair

Others

Parotid and lacrimal gland swelling (alcoholic liver disease)

Fetor hepaticus (characteristic sweet smelling breath)

Asterixis

Signs of Cirrhosis of Liver

Jaundice

Jaundice is not a common feature of cirrhosis, its more common with acute diseases.

Mechanisms of jaundice in cirrhosis:

Failure to excrete bilirubin (mainly)

Intrahepatic cholestasis (superadded hepatitis/tumor)

Hemolysis due to hypersplenism (not a major contributor).

Hepatomegaly

Early stages: Liver is enlarged, firm to hard, irregular, and non-tender. Hepatomegaly is not common

in cirrhosis but common when the cirrhosis is due to alcoholic liver disease, nonalcoholic

steatohepatitis (NASH) and hemochromatosis. Hepatomegaly may indicate transformation into

hepatocellular carcinoma (HCC).

Late stages: Liver decreases in size and non-palpable due to progressive destruction of liver cells

and accompanying fibrosis.

Ascites

Ascites due to liver failure and portal hypertension.

It signifies advanced disease.

(discussed in detail below)

Spider Naevi

Spider nevi (Fig. 5D.1)

(Spider telangiectasia; vascular spiders; spider angiomas; arterial spiders, and nevus araneus)

Description Consists of a central arteriole from which numerous small vessels radiate peripherally-resembling spider’s

legs. Whole spider disappears when central arteriole is compressed with a pinhead. When compression is

released filling occurs from center to periphery

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Pathophysiology Due to arteriolar changes induced by hyperestrogenism

Location Usually found only in the necklace area, i.e. above the nipples, territory drained by the superior vena cava,

such as: head and neck, upper limbs, front and back of upper chest

Size Vary from pinhead to 0.5 mm in diameter

Clinical

demonstration

Applying pressure over the body of spiders with a glass slide (diascopy) (Fig. 5D.2), or pin head (Fig. 5D.3)

leading to pallor with refilling following the release of pressure

Significance They are a strong indicator of liver disease but can be found in other conditions

Causes Liver disorders Others

Viral hepatitis

Alcoholic hepatitis

Hepatocellular carcinoma

Treatment with sorafenib

Third trimester of pregnancy

Rheumatoid arthritis

Thyrotoxicosis

Also normally seen in 2% of healthy population

Differential

diagnosis

Venous star, Campbell de Morgan spots, petechiae, and hereditary hemorrhagic telangiectasias

Note:

Florid spider telangiectasia, gynecomastia, and parotid enlargement are most common in alcoholic

hepatitis.

Florid spiders and new onset clubbing in a patient with cirrhosis indicates hepatopulmonary

syndrome.

Palmar Erythema (Liver Palm)

Can be seen early but is of limited diagnostic value, as it occurs in many conditions associated with a

hyperdynamic circulation (e.g. normal pregnancy).

Fig. 5D.1: Cirrhosis of liver with ascites and spider nevi. Patient in addition has tattoo and keloid—

which may suggest viral hepatitis as the cause of cirrhosis.

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Fig. 5D.2: Demonstration of spider naevi (glass slide method).

Fig. 5D.3: Demonstration of spider nevi (pin head method).

Cause: Develops due to increased peripheral blood flow. In cirrhosis, circulatory changes results in

increased peripheral blood flow and decreased visceral blood flow (especially to the kidneys).

Sites involved: Prominent in the thenar and hypothenar eminences of palm. Spares the central

portion of the palm. May be seen on the sole.

Endocrine Changes

Diminished body hair and loss of hair: Seen mainly in males with loss of male hair distribution.

Alopecia affects usually the face, axilla and chest and is due to hyperestrogenism. Causes of

hyperestrogenism: Due to increased peripheral formation of estrogen resulting from diminished

hepatic clearance of the precursor, androstenedione. Effects of hyperestrogenism: Alopecia,

gynecomastia, and testicular atrophy.

Hyperglycemia: 80% of cirrhotics have impaired glucose tolerance, 20% develop diabetes.

Gynecomastia (Fig. 5D.4): Found in males (atrophy of breasts in females).

Cause: Due to increased estradiol/free testosterone ratio.

Examination (Fig. 5D.5): Appear as palpable nodule (4 cm, subareolar).

Microscopy: Proliferation of glandular tissue of breast.

Pseudogynecomastia is accumulation of subareolar fat tissue without palpable nodule. Seen in obesity

and Cushing’s syndrome:

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Causes of gynecomastia

Cirrhosis of liver

Drugs:

Spironolactone

Cimetidine

Digoxin

Ketoconazole

Estrogens

Isoniazid/Antiandogens

Physiological (puberty/ageing)

Klinefelter’s syndrome

Hypogonadism

Tumor:

Testes

Lung

Testicular Atrophy

Due to hyperestrogenic state, it is characterized by a small size compared with Prader’s orchidometer

(Fig. 5D.6), soft testes with loss of testicular sensation (sickening sensation in epigastrium on squeezing

the testes). The dimensions of the average adult testicle is 4.5 × 3.5 × 2.5 cm and the volume is 15–25

mL.

Fig. 5D.4: Gynecomastia.

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Fig. 5D.5: Palpation breast bud in gynecomastia.

Fig. 5D.6: Prader’s orchidometer.

Endocrine changes in females

Irregular menses, amenorrhea, and atrophy of breast.

Dupuytren’s Contracture (It is a Sign of Alcoholism)

Pathophysiology Fibrosis of palmar aponeurosis probably caused by local microvessel ischemia. Platelet and

fibroblast-derived growth factors promote fibrosis

Sites involved Flexion contracture of the fingers (Fig. 5D.7) (especially ring and little fingers)

Other causes of

Dupuytren’s contracture

Diabetes mellitus, rheumatoid arthritis, and manual labor (workers exposed to repetitive handling

tasks or vibration).

Clubbing and Central Cyanosis

Due to development of pulmonary arteriovenous shunts that leading to hypoxemia (Orthodeoxia—

Platypnea syndrome).

Nail Changes

White (Terry’s) chalky and brittle nails (Fig. 5D.8). And it can be easily demonstrated on comparison

with normal person nails when placed side by side (Fig. 5D.9).

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Muehrcke’s nails: Characterized by transverse white lines that disappear on applying pressure and

these lines do not move with growth of nail.

Clubbing is present in primary biliary cirrhosis or hepatoma.

Parotid and Lacrimal Gland Enlargement (Fig. 5D.10)

Observed commonly in alcoholic cirrhosis due to associated autonomic dysfunction.

Anemia

It can be due to various causes:

Acute and chronic blood loss from varices

Fig. 5D.7: Dupuytren’s contracture.

Fig. 5D.8: White nails.

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Fig. 5D.9: Leukonychia—compare with nails of normal person (preferably hands to be placed side by

side).

Fig. 5D.10: Diminished facial hair with parotid enlargement.

Nutritional deficiency of vitamin B12 and folate

Hypersplenism

Bone marrow suppression by alcohol

Hemolysis

Zeives syndrome: Alcohol induced hemolytic anemia with hypercholestrolemia.

Fetor Hepaticus

Sweet, pungent smell

It is due to volatile dimethylsulfide, especially in portosystemic shunting and liver failure and hepatic

encephalopathy.

Asterixis/Flapping Tremor

Asterixis is a disorder of motor control characterized by an inability to actively maintain a position and

consequent irregular myoclonic lapses of posture affecting various parts of the body independently.

It is a type of negative myoclonus characterized by a brief loss of muscle tone in agonist muscles

followed by a compensatory jerk of the antagonistic muscles.

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