Introduction to clinical
gastroenterology
Šramková Michaela M.D., Poredská Karolína M.D.
History
GIT symptoms
 dyspepsia
 dysphagia
 nausea
 vomiting
 pyrosis
 diarrhoea
 constipation
 flatulence, meteorism
 weight loss (how much? time range?
on purpose? another consequences –
infection, tonsillitis, dental
problems..)
 GI bleeding (hematemesis, melena,
enterorrhagia/hematochezia)
 jaundice
Pain
 localization
 radiation
 duration, beginning of problems
 sudden/ gradual/ continuous/
intermittent/ crampy
 precipitating or alleviating factors
 dietary mistake (alcohol, fatty, spicy,
sour, peppery.. food)
 visceral/somatic
 deep/superficial
Clinical examination
 right position - patient lies on back with relaxed abdominal wall musculature
(head and knees supported on small pillow, arms at the sides)
 inspection, palpation, percussion, auscultation, DRE/per rectum!
 1.question – Does it hurt anywhere? – and we start the examination on the
other side; at first superficial, than deep palpation
 ascites, hernia – better to examine standing
 scars, herniation, hematoma, discoloration, striae...
 acute abdomen signs – defénse musculaire, Blumberg, Rowsing, Plenies signs
 McBurney´s point, Murphy sign, Courvoisier sign
Laboratory tests
 biochemistry: Na, K, Cl, Ca, Mg, P, urea, creatinine, bilirubin, liver enzymes – ALT,
AST, GGT, ALP, amylase, lipase, albumin, total protein, glucose, CRP
 hematology: full blood count, coagulation/blood clotting tests
 microbiology: stool (Clostr. difficile, Salmonella, Campylobacter, Yersinia..,
rotavirus, norovirus, adenovirus, parasites), ascites, aspiration from abscess,
H.pylori sensitivity for ATB
 serology : hepatitis A,B,C,E, EBV, CMS, immunoglobulins, autoantibodies for
diagnostic IBD (ANCA, ASCA), celiac disease (DGP, tTG, EMA), autoimmune
hepatitis (ANA, ANCA, ASMA, LKM..), H.pylori antigen in stool, faecal calprotectin
 immunohistochemistry : faecal occult bleeding test (FiOK/TOKS)
Special methods
 urea breath test – diagnostic of H.pylori infection
Histology
 liver biopsy, endoscopic biopsies, cytology from ascites..
Imaging methods
 X-ray of abdomen – ileus? pneumoperitoneum?
 ultrasonography of abdomen – free fluid? inflammatory focus – cyst/abscess?
pathological lymph nodes? cholecystolithiasis? cholecystitis? appendicitis?
v.portae thrombosis? malignancy? metastasis?
- image of pancreas in sonography is often limited (because of its position)
 ultrasonography of intestine
 CT of abdomen/pelvis (CT of pancreas for staging acute pancreatitis)
 MR of abdomen/ pelvis
 CT/MR enterography modification
 virtual CT colonography
 skiascopy – passage of contrast fluid through upper GIT, defecography
 enteroclysis, irigography
Endoscopic procedures
 gastroscopy – from mouth to D3
 colonoscopy – from rectum to terminal ileum
 enteroscopy – push enteroscopy, double-balloon enteroscopy
- examination of whole small intestine
 capsule endoscopy – video record of passage through whole digestive tract
 ERCP (endoscopic retrograde cholangiopancreatography) – examination of biliary/pancreatic
duct systems with contrast fluid and skiascopy
 EUS (endoscopic ultrasonography) – esophagus, stomach, pancreas, biliary ducts,
transrectal EUS
- evaluate depth of submucous invasion, pathological lymphadenopathy if there
is malignancy suspicion
- evaluate dilatation of biliary and pancreatic duct system, lithiasis, focal
inflammation – cyst/pseudocyst, malignancy
 esophageal pH-metry, 24h esophageal impedance – diagnostic of GE reflux disease
 esophageal / anorectal manometry – evaluation of motor function of
esophageal/anal sphincters
Endoscopic methods - interventions
 polypectomy
 ligation of esophageal/ gastric subcardial varices
 sclerotherapy of varices (Aethoxysclerol – tissue glue)
 balloon dilatation of strictures
 GI bleeding treatment – injection – Adrenalin
- mechanic – clips
- hemospray (inorganic powder)
- thermic – APC (argon plasma coagulation)
 PEG insertion (percutaneous endoscopic gastrostomy) – nutrition for patients with ORL
malignancy, malign/benign esophageal strictures, after strokes, severe
stadium of dementia
 EUS – navigated transgastric drainage of pancreatic cyst/pseudocyst
 ERCP – lithiasis extraction, stent insertion, biopsy
Thank you for your attention!
Sources:
DAMJANOV Ivan, Pathophysiology, 1st Edition, A STUDENT CONSULT Online, 2009,
ISBN 978-1416002291
ŠPINAR Jindřich et al., Propedeutika a vyšetřovací metody vnitřních nemocí,
2.vydání, GRADA, 2013, ISBN 978-80-247-4356-1
CHROBÁK Ladislav et al., Propedeutika vnitřního lékařství, 3.vydání, GRADA,
2007, ISBN 978-80-247-0617-7
http://new.propedeutika.cz