Introductory Final PYQ: GI Rapid Review

Note: This review is following the GI section of Lajneh final PYQ, and
does not necessarily cover all of the lecture slides.

By: Nadeem Alabdallah, MD, MRCS

Important Symptoms:

- Odynophagia: Pain with swallowing

- Dysphagia: Difficulty swallowing

- Dyspepsia: Nonspecific, discomfort or pain in the upper abdomen, often

after eating or drinking.

- Anorexia: Loss of appetite

- Nausea: Sensation of needing to vomit

- Vomiting: expulsion of stomach contents

- Projectile vomiting: forceful expulsion of stomach contents

- Hematemesis: Vomiting blood

- Melena: black, tarry stool (‫ >>> )زي اﻟزﻓﺗﺔ‬upper GI bleed

- Occult Fecal Blood: Blood in the feces that is not visibly apparent

- Hematochezia: Fresh blood per rectum >> Lower GI bleeding

- Tenesmus: Constant feeling that you have to go to the bathroom, even if

you've just emptied your bowels

- Pruritus Ani: Anal itching

Important incisions:

- Midline abdominal incision/scar: Laparotomy

- Kocher incision: Open Cholecystectomy

- Gridiron incision + Lanz incision: Acute appendicitis

- Midsternotomy scar: Coronary artery bypass graft (CABG)

- Mercedes Benz scar: Liver surgery

- Sub mammary scar: Mitral valvotomy

- Infraclavicular scar: Pacemaker placement

- Pfannestiel scar: Cesarean section

-
 Transpyloric Plane (upper transverse line):

- It is a plane half way between the pubic symphysis and the jugular

notch.

Or half way between the Xiphisternal joint (T9/T10 disc) and the

umbilicus (L4).

- It is at the level of the L1/L2 vertebral disc.

- Subcostal plane is located higher than the transpyloric. (‫)ﺳﻧوات‬

- Structures on the Transpyloric Plane:

Abdominal Pain:

- Visceral Pain: Dull and vague, follows embryology:

1- Foregut: Epigastric pain
2- Midgut: Periumbilical pain
3- Hindgut: Suprapubic pain
- Parietal (Somatic) Pain: Sharp and localized pain to the site of the
organ.
Abdominal Pain + radiates to the back:
- Acute Pancreatitis
- Acute Cholecystitis
- Abdominal Aortic Aneurysm
- Perforated peptic ulcer

Abdominal Pain + Referred to Right Shoulder >> Acute Cholecystitis

Abdominal Pain + Referred to left Shoulder >> Splenic Abscess
Periumbilical Pain + shifting to RIF >> Appendicitis
Abdominal Pain + Relieved by eating >> Duodenal Ulcer
Abdominal Pain + Relieved by fasting >> Gastric Ulcer
Generalized Abdominal Pain + rigidity >> Peritonitis
Abdominal Pain + Referred to groin >> Ureteric Stone
Peritonitis:
- pain in peritonitis is severe and generalized
- The patient tends not to do any movement to aggravate it.
- Not associated with food
- There is rigidity and absence of bowel sounds due to paralytic ileus.
- Rebound tenderness or tenderness on palpation are present.
- During examination avoid unnecessary maneuvers such as Patient
rolling on the bed.

Duodenal Ulcers:
- Pain localized to epigastric region
- Pain is exacerbated by fasting “Hunger Pain”
- Pain associated with NSAIDS
- Pain is decreased after eating
- Can lead to scarring of the stomach outlet >> Gastric outlet obstruction

Gastric Ulcers:
- Pain is localized in epigastric region
- Pain is relieved by antacid
- Pain is exacerbated by eating
- Pain is relieved by fasting
Gastric outlet obstruction:
- Narrowing or obstruction of the pylorus
- Can be due to:
1- Pyloric muscle hypertrophy
2- PUD or inflammatory fibrosis
3- malignancy causing obstruction
4- Bezoar obstructing
- Succession Splash: a sound heard by
stethoscope after moving abdomen back
and forth
- Projectile Vomiting: High pressure in
stomach leads to forceful vomiting of
stomach contents.
- Increased peristalsis may be noted
- NOT ass. w/ Venous Hum (‫)ﺳﻧوات‬

Ascites:

- It is the abnormal build-up of fluid in the abdomen.

- Causes generalized swelling of the abdomen
- Can be assessed on examination using:
1- Shifting Dullness
2- Transmitted thrill
- Can be either:
1- Exudate: TB / Infections / Nephrotic syndrome / most common is CA
2- Transudate: Cirrhosis (liver failure) / Heart failure / kwashiorkor.
Important Physical Exam Signs:
Hernias:

- Most common hernia in Everyone >> Indirect Inguinal hernia

- More common in Females >> Femoral Hernia

- More common in elderly >> Direct inguinal hernia

- More common in children >> Umbilical hernia

- Which hernia descends to the scrotum? A: Indirect inguinal hernia

- Which hernia occurs at the linea semilunaris? Spigelian hernia

- Herniation only of antimeseteric wall of the intestine > Richters Hernia

- Direct + Indirect hernia on same side >> Pantaloon Hernia

- Where is the epigastric hernia found?

At the midline (linea Alba) between the xiphoid and umbilicus.

- Hernias may contain hollow organs (ex. Bladder, intestines) NOT solid

organs (ex. Liver, spleen).

- Swelling + Previous surgical scar >> Incisional hernia

- Inguinal hernia bulges above and medial to pubic tubercle

- Femoral hernia bulges below and lateral to pubic tubercle.

- Femoral hernia goes into the femoral triangle medial to femoral vein.

- Femoral hernia has a narrow neck >> Higher risk of strangulation.

Intestinal Obstruction:

- It is an example of acute abdomen, and is a surgical emergency.

- Cardinal symptom >>> Pain, Constipation, Vomiting, Distension.

- High pitched bowel sounds are heard due to the obstruction.

- Most common cause is adhesions secondary to previous surgery.

Appendicitis:

- Starts as periumbilical pain then shifts to the right iliac fossa.

- Vomiting and nausea might occur.

- Special signs >> McBurney’s, Rovsings, Obturator, and psoas signs.

- Mostly affects teenagers and young adults.

- Is a cause of acute abdomen and is a surgical emergency.

Liver cirrhosis:

- Normal functioning tissue, or parenchyma, is replaced with scar tissue

and regenerative nodules as a result of chronic liver disease.

- Liver size shrinks >> liver span decreased

- Causes Hypoalbuminemia, bilateral lower limb edema, transudative

ascites, jaundice, and clubbing.

Cholecystitis:

- Most commonly due to cystic duct obstruction with gallstones.

- Presents with colicky pain that increases after meals.

- Pain may be referred to the right shoulder.

- Murphy’s sign: Palpation of the RUQ during inspiration causes abrupt

cessation of breathing due to pain.

- Courvoisier's Law: States that a painless palpably enlarged gallbladder

accompanied with mild jaundice is unlikely to be caused by gallstones

- Relieved by NSAIDS (Ibuprofen, diclofenac)

Obstructive Jaundice:

- Due to obstruction in the common bile duct.

- Most commonly caused by a slipped stone from the gallbladder

- Can also be caused by:

1- Cholangiocarcinoma of the CBD wall

2- Pancreatic head cancer

3- Biliary Strictures

- Painless Jaundice + elderly >> Rule out Cancer

- Patient becomes jaundiced due to hyperbilirubinemia

- Patient may report clay-colored stool and dark urine