Lecture #122: DPR: History and Physical Exam of the Gastroenterology II

What does sudden, severe abdominal pain indicate?

Sudden, severe pain (“like a light switching on”) suggests conditions such as a perforated ulcer, ruptured ectopic pregnancy, renal stone, torsion, or ruptured aneurysm.

Which abdominal pain pattern suggests peritonitis?

Sharp, constant pain worsened by movement and relieved by lying still indicates peritoneal irritation or peritonitis.

What does “pain out of proportion to physical findings” suggest?

It suggests mesenteric ischemia, where bowel ischemia produces severe pain with minimal tenderness early in presentation.

Which location of pain suggests cholecystitis?

Right upper quadrant pain that may radiate to the right scapula, often following fatty food intake, with nausea, vomiting, and positive Murphy’s sign.

What are typical causes of left upper quadrant pain?

Gastritis and splenic pathology such as rupture or abscess.

What causes right lower quadrant pain?

Appendicitis, cecal diverticulitis, or Meckel’s diverticulitis. Pain often begins periumbilically and localizes to McBurney’s point.

What causes left lower quadrant pain?

Sigmoid diverticulitis, which presents with localized tenderness, fever, and altered bowel habits.

What are causes of diffuse abdominal pain?

Peritonitis, pancreatitis, gastroenteritis, or mesenteric ischemia. Diffuse pain often indicates a more generalized inflammatory or metabolic process.

What are examples of referred abdominal pain?

Right scapula (gallbladder), left shoulder (spleen or pancreas), chest or shoulder (esophageal rupture), and suprapubic region (renal colic).

What is the correct order of the abdominal exam?

Inspection, auscultation, percussion, palpation, and finally special tests. Auscultation precedes palpation to avoid altering bowel sounds.

What are key special tests in the abdominal exam?

Assessment for ascites, Lloyd’s (CVA) tenderness, Murphy’s sign, McBurney’s point tenderness, rebound tenderness, Rovsing’s, Psoas, and Obturator signs.

What does shifting dullness on percussion suggest?

It indicates ascitic fluid accumulation. When the patient shifts position, dullness moves due to free fluid in the abdomen.

What is Lloyd’s sign and what does a positive result indicate?

Tapping the costovertebral angle elicits pain in renal inflammation. A positive test suggests pyelonephritis, perirenal abscess, or nephrolithiasis.

What is Murphy’s sign and what does it indicate?

Palpation of the right upper quadrant during inspiration causes abrupt cessation of breathing due to pain. A positive test indicates acute cholecystitis.

Where is McBurney’s point and what does tenderness there indicate?

Located one-third from the ASIS to the umbilicus; tenderness suggests acute appendicitis.

What is rebound tenderness and what does it suggest?

Pain upon sudden release of deep palpation indicates peritoneal irritation or peritonitis. If localized to the RLQ, appendicitis is likely.

What is Rovsing’s sign?

Pain in the right lower quadrant upon palpation of the left lower quadrant, suggestive of appendicitis due to peritoneal irritation.

What is the Psoas sign and what does it suggest?

Pain on resisted right hip flexion or passive extension of the right leg suggests irritation of the psoas muscle from retrocecal appendicitis.

What is the Obturator sign and what does it indicate?

Pain in the RLQ with internal rotation of the flexed right hip indicates a pelvic appendix or pelvic abscess irritating the obturator internus muscle.

What findings suggest acute pancreatitis?

Rapid onset of severe epigastric pain radiating to the back, nausea, vomiting, fever, and relief with forward bending, often due to alcohol or gallstones.

What are key signs of peritonitis?

Severe constant abdominal pain, guarding, rebound tenderness, and patient remaining motionless to minimize pain; may follow GI perforation.

What are signs of acute diverticulitis?

LLQ pain with fever, chills, mild abdominal distention, absent bowel sounds, and sometimes a palpable tender mass. Recurrence is common.

Which additional exams complete the GI physical?

Rectal exam (for blood, tone, masses), vaginal exam (for pelvic pathology), and testicular exam (for hernia or torsion assessment).

What are the main subtypes of primary constipation?

Normal transit, slow transit, and defecatory disorders (dyssynergia or anismus). Some patients have overlap conditions, sometimes with IBS features.

What is dyssynergic defecation?

Paradoxical contraction or inadequate relaxation of the pelvic floor or external anal sphincter during attempted defecation, leading to impaired stool passage.

What should be included in the constipation history?

Frequency, stool consistency, need for straining or manual evacuation, laxative use, and symptoms like bloating or pain.

What are key physical exam components in constipation evaluation?

Abdominal and rectal exams assessing for masses, fissures, hemorrhoids, sphincter tone, reflexes, and pelvic floor function.

What are common causes of new-onset constipation in hospitalized patients?

Opioids, calcium channel blockers, antihistamines, iron supplements, inactivity, dehydration, low-fiber diet, or electrolyte disturbances.

What conditions cause constipation with characteristic features?

Colon cancer (weight loss, anemia, hematochezia), IBS (bloating and pain), pelvic floor dysfunction (prolonged straining), and hypothyroidism (fatigue, slowed metabolism).

What are “red flag” findings requiring endoscopy in constipation?

Age >50 without prior screening, rectal bleeding, iron deficiency anemia, weight loss, change in stool caliber, or recent onset constipation.

What is the typical presentation of colon cancer?

Constipation alternating with diarrhea, narrow stools, weight loss, anemia, and hematochezia, often in older adults with risk factors such as high red meat intake.

What are the Rome IV criteria for functional defecation disorder?

At least 2 of: impaired evacuation, inappropriate pelvic floor contraction (<20% relaxation), or inadequate propulsive forces, with symptoms ≥3 months.

What are the Rome IV criteria for irritable bowel syndrome?

Recurrent abdominal pain at least 1 day per week for 3 months, associated with defecation, change in stool frequency, or change in stool form, with onset ≥6 months prior.

What symptoms suggest hypothyroidism as a cause of constipation?

Fatigue, depression, cold intolerance, muscle pain, brittle hair/nails, and weight gain in older females due to low thyroid hormone levels.

What is Chagas disease and how does it cause constipation?

Caused by Trypanosoma cruzi infection transmitted by triatomine bugs, leading to chronic constipation, megacolon, and volvulus from enteric nerve destruction.

What is the main management plan for functional defecation disorder?

Increase fluids and fiber, use biofeedback therapy for pelvic floor retraining, consider GI referral, behavioral therapy, and address somatic dysfunction with OMT.