Abdomen Semiotics

Importance and modalities of history taking and patient interviewing

• hypothetico-deductive model: collect information, form hypothesis, test it against evidence
  logical, evidence based approach

• need to gather information to determine the patients problem to make an accurate diagnosis

• establish trust and rapport with patient to gather necessary information to make a correct diagnosis

Essential elements of clinical care:

• empathetic listening

• able to interview all backgrounds and cultures

• process of clinical reasoning to find diagnosis

• need to be adaptable and able to improvise based on patient

• establish good relationship, introduce yourself

• let them decide about whether visitor stays or not

• open ended questions (not leading)

• active listening, empower the patient

• avoid bias, use multiple choice responses

History taking (9 steps)

1 - chief complaint
2 - history of present illness (OPQRST-A)
3 - past medical history (e.g. previous digestive diseases, infectious diseases, malignancy)
4 - past surgical history (operations in chronological order)
5 - allergies (medication, latex, food, seasonal)
6 - medications (even over-the-counter + herbal; dosage, medical reason for each)
7 - social history (occupation, marriage status, tobacco/alcohol/illicit drug use)
8 - familial history (major medical conditions)
9 - review of systems (general, skin/breast, eyes/ears/nose/mouth/throat, CVnR, GI, GU, MS, neurological/psychiatric, allergic/immunologic/lymphatic/endocrine)

Signs vs symptoms

signs are objective findings from physical examinations
symptoms are subjective concerns from the patient

OPQRST-A

O - onset: when did these symptoms first occur
P - prior occurence
Q - quality: is it stabbing or throbbing pain
R - radiation: does the pain 'spread' to other areas
S - severity: 1-10 scale
T - timing: when does the pain occur
A - associated symptoms like fever/ jaundice

order of medical examination steps

inspection
auscultation
palpation
percussion
- listen before palpation so you don’t move contents

Anatomical regions

4 quadrants: line from xiphoid process to pubic bone, line across along the umbilical region

9 regions: right hypochondriac, epigastric, left hypochondriac, right lumbar, umbilical, left lumbar, right iliac, hypogastric, left iliac

right hypochondriac region

liver, gallbladder (and most of the biliary tract), hepatic flexure of colon, right kidney (upper pole)

left hypochondriac region

• spleen - completely under the costal elements if spleen not enlarged

• fundus of stomach

• tail of pancreas

• left kidney (upper pole)

• splenic flexure of colon

epigastric region

• stomach

• left liver lobe

• duodenum

• pancreas (head and body)

right lumbar region

• ascending colon

• right kidney

• small intestine

• (if liver is enlarged the gallbladder may be here)

umbilical region

• small intestine (jejunum and ileum)

• transverse colon

left lumbar region

• Left kidney

• descending colon

• Small intestine

right iliac region

• appendix

• caecum

• ovary

hypogastric region

• bladder

• uterus (below bladder; if enlarged)

• sigmoid colon

• small intestine

left iliac region

• Sigmoid colon

• Left ovary and fallopian tube

diverticulitis normally found here

Possible findings in abdominal inspection

• skin changes

  • colour/ scars/ rashes/ stretch marks (straie) (purple straie can indicate crushing syndrome - overproduction of corticosteroids)

  • Portocaval venous patterns - caput medusae/prominent veins (portal hypertension)

• visible peristalsis or pulsations (intestinal obstruction, aortic aneurysm)

• localised bulges of abdominal wall: ventral hernias (umbilical, incisional, epigastric) + subcutaneous tumours (lipoma)

• diastasis recti (separation of rectus abdominis muscles; clinically benign; seen only when patient raises head and shoudlers)

• distended abdomen (obesity, ascites, organomegaly, bowel obstruction)

• Protuberant abdomen

• Bruising

  • Grey Turner sign =
    Pancreatitis causes bleeding in the flank area

  • Cullen’s sign = bruising in periumbilical region = ectopic pregnancy or acute pancreatitis

Protuberant abdomen

• Fat - dull sound

• Cancer - if tumour protrudes it is already very serious

• Gas - will hear tympanic percussion sounds that move when patient lies on side

• Pregnancy

Protuberant abdomen with bulging flanks:

• Ascites: fluid retention: taut and shiny skin

Possible findings in abdominal auscultation

Provides info about bowel motility

• Bowel sounds

  • clicks and gurgles (5-34/min)

  • occasionally, prolonged gurgles of hyperperistalsis from “stomach growling” called borborygmi

  • bowel sounds may be increased → diarrhoea, early intestinal obstruction

  • bowel sounds may be decreased then absent (listen for at least 2 mins before deciding they’re absent) → adynamic ileus, peritonitis

• High-pitched tinkling sounds → intestinal fluid + air under tension in a dilated bowel

• Rushes of high-pitched sounds + abdominal cramp → intestinal obstruction

• Venous hum

  • soft humming sound with systolic + diastolic components

  • increased collateral circulation between portal and systemic venous systems → hepatic cirrhosis

• Vascular bruits

  • Hepatic bruit → liver carcinoma, cirrhosis

  • Arterial bruit w/ systolic + diastolic components → partial occlusion of aorta/large arteries

    • In epigastrium → renal artery stenosis, renovascular hypertension

• Friction rubs

  • Rare grating sounds w/ respiratory variation

  • Inflammation of peritoneal surface of an organ → liver cancer, chlamydial or gonococcal perihepatitis, recent liver biopsy, splenic infarct

Systolic bruit + hepatic friction rub = liver carcinoma

Possible findings in abdominal percussion

• Tympanic (high pitched and hollow) = air, found at fundus of stomach or over intestines

• Localised tympany = trapped gas

• Excessive tympany = pneumoperitoneum = very dangerous

• Dull = solid → found over solid organs e.g. liver and spleen

• Hepatomegaly = dull sounds below the costal margin

• Ascites = moving dullness as fluid moves

• Giordano’s sign

Percussion tenderness of kidneys

Giordano’s sign

• If kidneys tender to palpation, assess percussion tenderness over CVAs. Place the ball of one hand in CVA + strike with ulnar surface of fist

Possible findings in abdominal palpation

• Start with light palpation and on the opposite side to where they are experiencing pain

  • detects abdominal tenderness, muscular resistance, some superficial organs + masses

• McBurney's + Lanz Point: Appendicitis.

• Murphy's (gallbladder) Sign: Acute cholecystitis.

• Superior + inferior ureteral points

• Rovsing's Sign: Referred pain in RLQ on palpation of LLQ (appendicitis).

• Cullen's Sign: Periumbilical tenderness with discoloration (pancreatitis, retroperitoneal haemorrhage).

• Grey Turner's Sign: Flank tenderness with discoloration (retroperitoneal haemorrhage).

Deep Palpation → to delineate the liver edge, kidneys + abdominal masses

palpation point: gallbladder

Firmly palpate RUQ subcostal region, pushing under ribs. Ask patient to take deep breath - pain = cholecystitis → Murphy’s sign

Visceral pain

• Occurs when hollow abdominal organs (e.g. intestine or biliary tree) contract unusually forcefully or are distended or stretched.

• Solid organs (e.g. liver) can become painful when their capsules are stretched.

• May be difficult to localise

• Typically palpable near midline (levels vary according to structures involved)

• Ischemia also stimulates visceral pain fibres

Parietal pain

• Originates from inflammation of the parietal peritoneum i.e. peritonitis.

• Steady, aching pain that is usually more severe than visceral pain

• More precisely localised over involved structure.

• Typically aggravated by movement or coughing. 

• Patients with parietal pain usually prefer to lie still.

In contrast to peritonitis, patients with colicky pain from a renal stone move around frequently trying to find a comfortable position.

Characteristics and main causes of gallbladder pain

• Causes (Clinical): Biliary colic, cholecystitis, ascending cholangitis

• Onset: Can appear after meals, especially if abundant/rich (e.g. fats, eggs)

• Quality: Acute, in waves (colicky pain; increasing intensity), in the right hypochondriac region and epigastrium.

• Radiation: Possible radiation to the homolateral shoulder and to the back.

• Associated Symptoms: 

  • Nausea (common)

  • Vomiting (common)

  • Bloating (common)

  • Sweating, fever, chills (if infection)

  • Jaundice (if cholangitis or biliary obstruction)

• Underlying Causes (Pathophysiological):

  • Gallstones are most asymptomatic - they cause symptoms when they cause obstructions .

  • Obstruction of the gallbladder (in the cystic duct)

    • Biliary colic (nausea, pain, vomiting)

    • Acute cholecystitis (fever)

  • Obstruction of the bile duct

    • Obstructive jaundice

    • Cholangitis (jaundice, fever)

    • Pancreatitis (jaundice, fever, pancreatic pain)

Gallstone ileus is a rare complication after a long history of large gallstones causing pressure on gallbladder wall with the formation of a fistula with the duodenum.

Characteristics & Main Causes of Pancreatic Pain

Pancreatic pain is primarily caused by pancreatitis, which is an inflammation of the pancreas. 

Under normal circumstances, pancreatic enzymes activate only within the duodenum to aid digestion.

However, during pancreatitis, these enzymes activate prematurely inside the pancreas itself due to the blockage of the pancreatic duct. As these enzymes are designed to digest proteins, they effectively begin to digest the pancreatic tissue, leading to a self-destructive cycle.

This condition can escalate quickly and become life-threatening.

• Causes: Choledocolithiasis, alcohol abuse

• Onset: Can appear after meals, especially if abundant/rich (e.g. fats, eggs)

• Quality: Starts in waves (colicky pain) in epigastrium, then becomes constant

• Radiation: Belt-like radiation, to the back

• Associated Symptoms: 

  • Nausea

  • Vomiting

  • Sweating

  • Fever

  • Chills

  • Jaundice

Characteristics of Pain Related to Abdominal Aorta Aneurysms

• Aortic aneurysms often grow slowly and usually without symptoms. Predicting how fast an aortic aneurysm may enlarge is difficult.

• Symptoms of abdominal aortic aneurysm enlargement:

  • Pulsating feeling near the navel

  • Deep, constant pain in abdomen

  • Back pain

Impending Aneurysm Rupture

• Onset: Sudden, intense and persistent abdominal or back pain → often reported as a tearing sensation

• Radiation: To the back of the legs

• Associated Symptoms: Dizziness, sweatiness (forehead), nausea and vomiting

• Physical Examination:

  • Low blood pressure with fast pulse

  • Asymmetric peripheral pulse in the lower limbs

Characteristics of Splenic Pain, Palpation of the Spleen, and Causes of Splenomegaly

Not in slides: Normally, the spleen is not palpable unless significantly enlarged. Examiner starts palpation in the RLQ and moves diagonally towards the LUQ (following splenic enlargement). With deep inspiration, a large spleen may be felt descending below the costal margin.

Pain originating from the spleen is a rare phenomenon. The spleen‘s parenchyma, similar to that of the liver, lacks nocicepters, making it incapable of directly sensing pain. However, pain may arise from the capsule or the peritoneum surrounding the spleen when these regions are affected. For pain to manifest, the sub-capsular region of the spleen must be involved.

Splenomegaly

• Causes of Splenomegaly: 

  • Portal hypertension (e.g. liver cirrhosis → increased pressure in portal vein)

  • Hematologic diseases (e.g. leukemia, lymphoma) 

  • Metabolic and congenital diseases (e.g. Gaucher disease → lipid infiltration of the spleen)

  • Infections (e.g. mononucleosis → spleen is a key player in immune system)

• Enlargement of the spleen itself does not cause pain, but it can increase the risk of:

  • Infarctions (due to disrupted blood flow).

  • Ruptures or lacerations (as an enlarged spleen is more fragile).

Infarction (spleen)

• Cause: Blockage of the splenic artery, often from metastatic septic emboli (e.g., from endocarditis)

• Sudden-onset pain in the LUQ (left upper quadrant) and posterior ribs.

• Referred to the left shoulder (Kehr’s sign).

• Pain can range from a dull ache to a sharp, stabbing sensation.

Rupture (spleen)

• Leading cause: Trauma (e.g., direct blow to the abdomen, car accidents).

• Symptoms:

  • Severe internal bleeding → Signs of shock (hypotension, rapid pulse, sweating).

  • Pain may not be immediately obvious, as general symptoms (shock) can mask abdominal discomfort.

  • If due to trauma, rib fractures may be the primary source of pain.

Signs & Symptoms of Peritonitis and Possible Causes

• Steady, aching pain

• Can be localised or generalised

Generalised Peritoneal Pain

• Primary Peritonitis (liver cirrhosis with ascites, complications from peritoneal dialysis) 

• Secondary Peritonitis (bowel perforation, abscesses or other infectious conditions)

Localised Peritoneal Pain

• Arises from local irritation of the peritoneum, usually due to an infectious process (cholecystitis, colonic diverticulitis, appendicitis)

• It is well-localised and typically in close proximity to the affected organ.

Rebound Tenderness (Blumberg Sign)

• Definition: Rebound tenderness is felt when the abdominal wall is compressed slowly and then released rapidly, causing a sudden stab of pain.

• This may make the patient wince or moan in response. Observing the patient’s facial expression during this test is crucial.

• Mechanism of Pain: The pain occurs due to a tuning-fork action, where inflamed visceral and parietal peritoneum come into contact during the release, creating a vibratory-like movement.

Possible Manifestations/Characteristics of Periumbilical Abdominal Pain

• Early appendicitis

• Mesenteric ischemia

• Gastroenteritis 

• Small bowel obstruction (SBO)

• Meckel’s diverticulitis

• Umbilical hernia

• Abdominal aortic aneurysm (AAA)

Acute Appendicitis: Signs & Symptoms

• Dull pain starting the umbilical region. 

• As time passes, the pain increases and becomes localised in the RLQ (with aching features)

• Associated symptoms: nausea, fever, loss of appetite, weakness

• McBurney sign: tenderness at McBurney’s point (might not be present at the symptoms’ start)

• Rovsing sign: Palpation in the LLQ elicits pain in the RLQ

• Dunphy’s sign = pain when patient coughs

• Rebound tenderness

Dyspepsia

Going from most to least common diagnoses in patients with dyspepsia (upper abdominal discomfort):

• Functional dyspepsia

• GERD

• Peptic ulcer

• Esophago-gastro-duodenal malignancies

Alarming signs in Dyspepsia

• Age > 50 years (malignancies more prevalent)

• Unintentional weight loss

• Dysphagia (difficulty swallowing)

• Anemia 

• Persistent vomiting

• Gastrointestinal bleeding (in vomit or stool)

• Jaundice (yellow skin/sclera)

Possible Manifestations/Characteristics of RUQ Abdominal Pain

(Not in slides)

Characteristics:

• Steady or sharp pain that is persistent or intermittent; radiates to back

• Tenderness to palpation

• Referred pain in right scapula

• Biliary colic: intermittent, cramping pain

• Nausea, vomiting, fever, chills

• Jaundice, pale stool, bloating, swelling

• Murphy’s sign

• Pain aggravated by fatty foods

• Liver enlargement, ascites

Potential Causes

• Gallstones

• Cholecystitis

• Cholangitis (bile duct inflammation)

• Hepatitis

• Liver abscess

• Hepatic cysts

• Liver tumours

• Duodenal ulcers

• Hernia

Definition & Related Causes of Heartburn and Regurgitation

• Heartburn: Rising retrosternal burning pain or discomfort. 

  • Can be aggravated by foods e.g. alcohol, chocolate, citrus fruits, coffee, onions, and peppermint

  • Can be aggravated by positions e.g. bending over, exercising, lifting, or lying supine.

  • Pain may radiate up to throat

• Regurgitation: Rise of oesophageal or gastric contents without nausea or retching. 

Regurgitation is a passive act.

Both usually go hand in hand, caused by GERD

Definition & Related Causes of Dysphagia and Odynophagia

• Dysphagia: Difficulty swallowing

• Odynophagia: Painful swallowing

Food that seems to stick or “not go down right” suggests motility disorders or structural anomalies. 

The sensation of a lump or foreign body in the throat, unrelated to swallowing, is called a globus sensation; it is not true dysphagia.

• Ask the patient to point to where the dysphagia occurs. 

• Ask which types of food provoke symptoms: solids, or solids and liquids? 

• Establish the timing. 

  • When does the dysphagia start? 

  • Is it intermittent or persistent? 

  • Is it progressing? If so, over what time period?

• Are there associated symptoms and clinical conditions?

Esophageal Dysfunction (Mechanical Obstacles)	Neurological Disorder
Cancer Solids → progresses to solids and liquids Persistent Weight loss, nausea	Swallowing liquids requires more coordination than solids. Liquids  Persistent + progressing Cough (caused by neurodegenerative diseases; liquids frequently get into airways)

Normal Bowel Movements & Stool Shapes

Bristol Stool Chart (not used in a clinical setting; useful for patients and students)

• Type 1: Separate hard lumps (severe constipation)

• Type 2: Lumpy and sausage-like (mild constipation)

• Type 3: A sausage shape with cracks in the surface (Normal)

• Type 4: Like a smooth, soft sausage or snake (Normal)

• Type 5: Soft blobs with clear-cut edges (lacking fibre)

• Type 6: Mushy consistency with ragged edges (mild diarrhoea)

• Type 7: Liquid consistency with no solid pieces (severe diarrhoea)

The range of normal frequency for bowel function is broad: 3 times a day to 3 times a week.

Abnormal Stool Colours and Related Causes

• Acholic stools: White, cretaceous stools due to lack of stercobilinogen (complete biliary occlusion -> gallstone/cancer)

• Mucus: Can be found as yellow flakes in a series of non-concerning situations (irritation of muciparous glands)

  • The combination of liquid stools with blood, pus and mucus suggests infectious or ulcerative colitis 

• Steatorrhea: Loose, greasy, yellowish stools due to lipid malabsorption. Might be bulky and hard to wash. Usually found in pancreatic failure (chronic pancreatitis, cystic fibrosis)

• Black = melena

• Red = hematochezia

• Silver stools (Thomas’s sign): Extremely rare due to the coexistence of melena and acholic stools. Reported in biliary tract cancer.

Definition & Causes of Melena

• Melena: Black, tarry (and usually liquid) stools indicating the presence of digested blood

  • Upper GI bleed (proximal to ligament of Treitz → oesophagus, stomach, duodenum)

• Causes:

  • Esophageal varices (from cirrhosis, portal hypertension)

  • Gastritis

  • Peptic ulcer disease

Definition & Causes of Haematochezia

• Haematochezia: Passage of fresh, bright red blood in the stool (often as coating stripes, at the end of evacuation)

  • Lower GI bleed (colon, rectum, anus)

  • Diverticular diseases

  • Haemorrhoids

  • Anal fissures

  • Polyps

  • Rectal cancer

Definition & Types of Diarrhoea

• Definition: Painless loose or watery stools during at least 75% of defecations (at least 3 evacuations per day) for the last 3 months, with symptom onset at least 6 months prior to diagnosis.

• Duration: 

  • Acute diarrhea: Less than 2 weeks.

    • Infections (viral, bacterial)

  • Chronic diarrhea: 4 or more weeks.

• 4 types: secretory, osmotic, inflammatory, motor

Types of diarrhea

• Secretory diarrhea: Increase of intraluminal salt secretion (recourse liquids -> water drawn into intestines)

  • Causes: Bacterial toxins, drugs, malignancies (NHL, colonic cancer), bile acid malabsorption

  • Usually > 1L / day

  • Frequency does not reduce with fasting

• Osmotic diarrhea: Presence of non-absorbable compounds, e.g. certain sugars draw water into the intestines, e.g. lactose intolerance

  • Usually < 1L/day

  • Disappears with fasting

• Inflammatory diarrhea: Damage to the integrity of intestinal barrier

  • Causes: Infections (e.g. cholera), drugs

  • Usually > 1L / day

  • Frequency does not reduce with fasting

• Motor diarrhea: Alteration in bowel motility

  • Drugs, electrolyte imbalance, endocrine diseases (e.g. hypothyroidism, hyperthyroidism, diabetes)

History Taking in Patients with Diarrhoea

• Duration (to decide if acute or chronic)

• Volume, frequency, consistency

• Is there mucus, pus or blood?

• Does it occur at night? (Nocturnal diarrhoea is usually pathological; not functional)

• Is there associated tenesmus - a constant urge to defecate (but no evacuation) - accompanied by pain, cramping and involuntary straining?

• Are the stools greasy or oily? Frothy?

Constipation identification + what to ask patient

Stool characteristics identified by the Rome III criteria:

• Constipation should be present for the last 3 months

• Symptom onset at least 6 months prior to diagnosis and meets at least two of the following conditions:

  • Fewer than 3 bowel movements per week

  • 25% or more defecations with either straining or sensation of incomplete evacuation

  • Lumpy or hard stools

  • Manual facilitation 

• Check if the patient actually looks at the stool and can describe its color and bulk.

• What remedies has the patient tried? 

• Do medications or stress play a role? 

• Are there associated systemic disorders?

Classification of Constipation

1. Episodic Acute Constipation

• Contingent situation

  • Lifestyle modification (environment, diet)

  • Iatrogenic (e.g. after surgery)

  • Immobilisation

  • Acute diseases

  • Pregnancy (especially in last month)

2. Chronic Constipation

   a. Secondary Constipation

   • Reversible

     • Stenosis

     • Hypothyroidism

     • Hypercalcemia

     • Drugs

   • Irreversible

     • Neurological diseases

     • Myopathies (muscle disease)

     • Cognitive disorders

   b. Functional Constipation

   • No organic diseases

   • Alternation in mechanisms of colorectal-anal motility and sensitivity.

Constipation - medical history + physical examination

Medical History

• Evaluate if symptoms are consistent with the definition of constipation and require further investigation.

• Investigate about diet and habits.

• Rule out systemic diseases or drugs causing constipation.

Physical Examination

• Look for alarming signs and indications for further testing (colonoscopy)

  • Age > 50 years (oncologic prevention)

  • Blood in stool

  • Recent worsening of symptoms

  • Nocturnal pain

  • Unsatisfactory response to cathartics (laxatives)

  • Fever

  • Anemia

  • Pathological findings at rectal examination (especially rectal exploration)

• Rectal examination for hemorrhoids, polyps, fecal impaction (hard lump of feces), etc.

Ileus

Ileus is the disruption of the normal propulsive ability of the intestine (fails to guarantee the normal progression of its content from mouth to anus).

Do not confuse it with constipation. Constipation is slowed transit/evacuation with no associated symptoms (except bloating). Ileus is disrupted motility or obstruction and is always associated with clinical manifestations apart from merely “no evacuation”, i.e. absence of flatus, colicky pain, vomiting, etc.

Paralytic Ileus

• Loss of normal intestinal contraction

• Causes: Abdominal surgery (sliced peritoneum needs time to heal), drugs (opioids; contribute, but not direct cause), peritonitis, hypokalaemia (low serum potassium) 

• Symptoms: Nausea, vomiting, mild abdominal discomfort 

• Physical examination: No bowel sounds

Mechanical Ileus (aka Bowel Obstruction)

• Normal contraction, but obstacles are obstructing the intestine

• Causes: Tumors, peritoneal adhesions, hernias, diverticulitis (inflammation of last part of colon), volvulus (strangles part of intestine), gallstone (rare)

• Symptoms: vomiting, abdominal colicky pain, no bowel function (no flatus, no stool)

• Physical examination: Hyperactive, high-pitched bowel sounds

Causes, Signs and Symptoms of Bowel Obstruction

Bowel obstruction = mechanical ileus

Symptoms

Pay attention to the order of the symptoms

Proximal Obstruction

1. Vomiting 

2. Pain

3. No bowel function

Medium-Level Obstruction

1. Pain

2. No bowel function 

3. Vomiting 

Distal Obstruction

1. No bowel function

2. Pain

3. Vomiting 

Causes, Signs & Symptoms of Bowel Perforation

• Bowel perforation is an insult or injury to the mucosa of the bowel wall causing a violation of the closed system.

• Causes:

  • Bowel obstruction

  • Bowel ischemia (inadequate blood supply)

  • Gastric or duodenal ulcer disease

  • Diverticular disease

  • Infection

  • Gastrointestinal tumors

  • Trauma: blunt or penetrating

  • Iatrogenic, e.g. perioperative 

• Clinical Presentation:

  • Sudden and severe abdominal pain

  • Sometimes with localised peritonism (symptoms suggesting peritoneal inflammation or irritation) or a rigid abdomen on examination. 

  • There may be an initial relief of pain as the dilated bowel collapses.

  • The pain begins again when peritonitis develops.

• X-ray will show free air in the peritoneum - surgical emergency

Definition & Types of Jaundice

• Yellowish color of skin and sclerae from increased levels of bilirubin

• Normal range: 

  • Total bilirubin (direct/conjugated + indirect/unconjugated) = 0.2-1.2 mg/dL

  • Direct (conjugated) bilirubin = 0.1-0.4 mg/dL

• Bilirubin levels > 2.0-2.5 mg/dL (visible on sclerae)

• Bilirubin levels > 3 (visible on skin)

• Total bilirubin (with high direct bil) >= 9.5 mg/dL (obstructive jaundice)

Types of Jaundice

1. Pre-hepatic 

• Heme overflow: hemolysis

• Genetic error in liver uptake → Gilbert disease

2. Hepatic

• Liver diseases: hepatitis and cirrhosis

• Genetic error in conjugation → Crigler-Najjar syndrome (infants; rare)

3. Post-hepatic

• Bile duct obstruction

• Genetic error in secretion → Dubin-Johnson and Rotor disease

Painful jaundice does not point to stones, but rather compressive obstruction (often pancreatic or biliary tumors) or cirrhosis (but in these cases, mixed bilirubin).

Associated Symptoms with Bile Duct Obstruction and Jaundice

• Color of urine (dark red/brown)

• Skin itch without other explanation (in cholestatic or obstructive jaundice)

• Pain (distended liver capsule, biliary colic, pancreatic cancer)

• Acholic stool (briefly in viral hepatitis, common in obstructive jaundice)

Jaundice + acholic stool = obstructed bile duct

Symptoms Potentially Associated with Jaundice

• Severe abdominal pain and tenderness → cholecystitis, pancreatitis

• Changes in mental function (drowsiness, agitation/confusion) → cirrhotic liver failure

• Blood in stool or tarry black stool (melena), blood in vomit (hematemesis) → portal hypertension

• Fever → cholangitis

• Weight loss, anorexia → pancreatic cancer

Jaundice due to haemolysis…

• Jaundice due to haemolysis results in an increase of indirect (unconjugated) bilirubin, which cannot pass in the urine.

• The excess unconjugated bilirubin is metabolised as urobilinogen, which can pass in the urine.

• Urobilinogen is colourless, but if the urine is exposed to light, it may assume a bright orange colour

Signs & Symptoms of Inguinal Hernia

Inguinal hernia occurs when part of intestine protrudes through a weak spot in abdominal muscles to create a bulge

• More common in men than women

There are 2 types:

1. Indirect: most common, all ages, both sexes, above inguinal ligament near midpoint, often courses to scrotum

2. Direct: less common, older men, rare in women, above inguinal ligament close to pubic tubercle, rarely courses to scrotum

Signs and symptoms:

• visible bulge in groin area especially when standing or straining

• groin discomfort, pain or discomfort when coughing

• localised swelling

• tenderness to touch, feeling pressure or heaviness in groin

• increased pain with physical activity

• changes in bowel movements: in some cases hernia become strangulated and compromise blood supply

Definition & Causes of Dysuria, Urgency and Frequency in Urinary Bladder Voiding

• Dysuria: painful urination (UTI, STI, urinary stones, intestinal cystitis)

• Urgency: sudden need to void (bladder infection, OAB, bladder stones, neurological conditions)

• Frequency: frequent voiding (diabetes, UTI, diuretic medications, bladder disorders, bladder outlet obstruction)

Alterations in urinary frequency + causes

• Polyuria: urine output > 2L/day

  • Causes: excess water intake, diabetes insipidus, renal diseases, drugs (diuretics)

• Oliguria: urine output < 1L/day

  • Causes: Reduction of renal blood flow (shock, haemorrhages, severe infections, heart failure), renal diseases

• Anuria: urine output < 100 cc/day

  • Same causes as oliguria but indicates a severe condition. The kidneys are not able to produce urine.

Anuria vs urinary retention

Anuria: The bladder is empty because the kidneys are not producing urine.

Urinary retention: The bladder is full and cannot empty because of an obstruction.

Urinary colours + causes

• brown - conjugated bilirubin in urine = severe liver disease/ obstructive jaundice

• purple - bacterial infection causes sulphatase/ phosphatases in urine, occurs in constipated women

• clear to dark yellow indicates level of dehydration

• orange urine can be caused by B12 / A

Definition & Characteristics of Hematuria

• Blood in urine

• haemoglobinuria = haemoglobin, not intact RBCs, in urine - looks more pale than haematuria

• Causes: UTI, kidney stones, cancer

Definition & Classification of Urinary Incontinence

Unintentional urination

• Stress incontinence (momentary leakage of small amounts of urine with coughing, laughing, sneezing while person is in upright position; urine loss unrelated to conscious urge to urinate)

• Urge incontinence (involuntary urine loss preceded by an urge to void; moderate volume)

• Overflow incontinence (detrusor contractions insufficient to overcome urethral resistance, causing urinary retention)

• Functional incontinence (on the way to toilet or only in the early morning)

Signs & Symptoms of Reno-ureteral Colic

• acute, severe pain caused by obstruction of urinary tract, ureter and pelvis distention

Signs and symptoms:

• location: flank pain begins in lower back and radiates to lower abdomen

• quality: sharp and intense

• onset: sudden

• duration: intermittent episodes

• aggravating factors: physical activity

• relieving factors: rest and change in positions

• urinary symptoms: hematuria, frequency, urgency

• associated symptoms: nausea, vomiting, flank tenderness, fever and chills

Signs & Symptoms of Epididymitis

• inflammation of epididymis, can be due to infection or other inflammatory conditions

• sexually transmitted diseases are a common cause of epididymitis

Signs and symptoms:

• testicular pain: localized to one testicle and may be gradual or sudden onset, may radiate to lower abdomen or groin

• swelling: tenderness and swelling in affected testicle

• redness of scrotal skin

• dysuria: painful urinating

• frequency and urgency of urination

• discharge from penis

• fever and chills

• enlarged lymph nodes in groin

• pain during ejaculation and physical activity

• Prehn’s sign: relief of pain when scrotum is elevated