(8) Gastrointestinal and Hepatic Assessment

Topics we covered

• Alarm Symptoms/Disease

• Physical Exam/Labs/Diagnostics

• Medications

Alarm Symptoms

• Vomiting >24 hrs; diarrhea >48 hrs

• coffee-ground, blood/ vomit

• Black/tarry or bloody stool; Pencil-thin stool

• Dysphagia = Difficulty swallowing/ Odynophagia = Painful swallowing

• constipation + no gas

• weight loss, fever, lethargy, confusion,

• Chest pain radiating elsewhere → Cardiac concern

• severe headache/stiffness

Disease Overview

1. GI System (Stomach + Intestines + Rectum)

2. Hepatobiliary System (Liver + Gallbladder)

3. Pancreatic System

• ⭐⭐⭐ RUQ → Liver, gallbladder

• ⭐⭐⭐ RLQ → Appendix

• ⭐⭐⭐ LLQ → Sigmoid colon

• ⭐⭐⭐ Epigastric → Stomach, pancreas

Disease

GI System (Stomach + Intestines + Rectum)

Disease	Memorize THIS
Dyspepsia (symptom)	Epigastric discomfort, bloating, burping
GERD	Substernal burning + sour taste worse lying down symptom-based diagnosis, PPI response
PUD	Epigastric pain H. pylori/NSAIDs (cause) EGD + biopsy
Gastroparesis	Early satiety Delayed emptying WITHOUT obstruction diabetes = Risk factor
Bowel obstruction	Pain + constipation + NO gas CT Previous abdominal surgery = Major risk factor
GI bleeding	Blood in vomit/stool ↓ Hgb/Hct
Appendicitis	RLQ + rebound tenderness CT
Diverticulitis	LLQ + constant pain CT
IBS	Pain + diarrhea/constipation ≥3 months symptom-based, no inflammation Stress worsens symptoms Bristol stool types 1–2 = Constipation; 6–7 = Diarrhea
Crohn's (IBD)	RLQ + chronic diarrhea DEEP, SKIP lesions
UC (IBD)	LLQ + BLOODY diarrhea SUPERFICIAL, CONTINUOUS

Rectal/Anal Disorders

• Hemorrhoids → Usually painless bleeding, itching.

• Fissure → Sharp, tearing pain + blood.

• Fistula → Tunnel/opening + discharge.

• Abscess → Constant throbbing pain + swelling.

What other topics we talk about in GI System

GI bleeding terms

• Melena → Black/tarry stool → Upper GI bleed.

• Hematochezia → Bright red blood in stool→ Usually lower GI bleed.

• Hematemesis → Blood in vomit.

Disease

Hepatobiliary System (Liver + Gallbladder)

Disease	Memorize THIS
Hepatitis	Liver inflammation
Cirrhosis	Liver scarring Ascites, jaundice, confusion Compensated = May be asymptomatic; decompensated = Ascites, confusion, jaundice Abnormal liver labs Child-Pugh = Cirrhosis severity.
Cholecystitis	RUQ + fatty foods (trigger) + positive Murphy's sign
Cholelithiasis	Gallstones
Choledocholithiasis	Stones in the bile ducts

Disease

Pancreatic System (Pancreas)

Disease	Memorize THIS
Acute pancreatitis	Severe epigastric pain → back gallstones/alcohol ↑ lipase/amylase
Chronic pancreatitis	Dull aching pain long-term smoking/alcohol

Physical Exam

• Murphy's → Cholecystitis

• Rovsing's/Psoas → Appendicitis

• Rebound tenderness → Appendicitis/peritonitis

• Absent bowel sounds → Ileus/late obstruction

• Hyperactive bowel sounds → Diarrhea/early obstruction

• Fluid wave → Ascites

• Jaundice → Liver disease

Labs

Finding	Think
AST/ALT/ALP ↑	Liver injury
Ammonia ↑	Liver disease → Confusion
Albumin ↓, INR ↑	Cirrhosis
Amylase/Lipase ↑	Pancreatitis
Hgb/Hct ↓	GI bleeding
CRP/ESR ↑	Inflammation
Fecal calprotectin ↑	IBD

↑ Bilirubin = Liver/biliary disease; jaundice

Harjinder Cooks Food 4 Anu

Diagnostics

• EGD → Upper GI/PUD.

• Colonoscopy → Lower GI/IBD + + BOWEL PREP.

• CT → Appendicitis, diverticulitis, obstruction.

• CT contrast → Check kidney function/medication interactions.

• HIDA → Gallbladder function.

• MRCP → Noninvasive bile/pancreatic ducts.

• ERCP → Invasive; removes stones.

• Ultrasound → Gallstones, liver evaluation

• Stool antigen or urea breath test → H. pylori

Flexible sigmoidoscopy	⭐ Examines rectum + sigmoid colon
Capsule endoscopy	⭐ Swallowed camera → Investigates bleeding when other scopes are inconclusive
Abdominal X-ray	⭐ May be used initially for bowel obstruction; CT helps confirm
Paracentesis	⭐ Removes ascitic fluid; can test for infection

Medications

Problem	Culprit Drugs / Key Consideration
Constipation	⭐ Ca/Al antacids, CCBs, opioids, TCAs, iron
Diarrhea	⭐ Mg antacids, laxatives, antibiotics, metformin
Nausea/Vomiting	⭐ Chemotherapy, opioids, antibiotics, GLP-1 drugs
GERD	⭐ NSAIDs, CCBs, bisphosphonates, GLP-1 drugs, anticholinergics; iron/aspirin → Esophageal irritation
PUD	⭐ NSAIDs, aspirin; NSAIDs + steroids → ↑ Ulcer risk
Gastroparesis	Opioids, GLP-1 drugs, anticholinergics
GI Bleeding	Anticoagulants, antiplatelets, NSAIDs
Bowel Obstruction	🚨 Avoid laxatives/prokinetics
Pancreatitis	Azathioprine, valproate, HCTZ, steroids, estrogens, opioids
Cirrhosis	Impaired liver metabolism → May require dose adjustments