--- module: 049-01 language: en chapter: 49 title: "Gastrointestinal History, Examination, Investigations, and Acute Presentations" module_title: "Foundations" source_sha256: 72190f16a231d5a1d56414c0497199e79d77d42b054d7518fa891ec45d9772d7 --- # Gastrointestinal assessment foundations ## Orientation ### Symptoms converted into an anatomical, physiological model ### Urgency judged at the bedside simultaneously ### Each symptom spans benign to malignant causes ### Safest approach #### Define onset and trajectory #### Localise the likely compartment #### Assess hydration and perfusion #### Search for peritonitis or obstruction #### Tests answer explicit questions ## Symptom history ### Pain: onset, site, radiation, character, colic #### Visceral pain diffuse, midline via shared afferents #### Parietal inflammation: sharp local pain, guarding #### Migration informative but patterns imperfect #### Sudden maximal pain needs urgent evaluation ### Vomiting: volume, colour, bile, blood, faeculent #### Repeated vomiting loses chloride and hydrogen ##### Contraction alkalosis, low potassium, kidney injury #### Faeculent: distal obstruction or fistula #### Distinguish regurgitation and rumination ### Dysphagia: initiation, solids, liquids, progression ### Dyspepsia is a symptom cluster, not a diagnosis ### Bowel habit: baseline, blood, nocturnal, steatorrhoea #### Coating versus mixed blood cannot exclude proximal disease #### Iron and bismuth darken stool without bleeding ### Jaundice: urine, stool, pruritus, exposures #### Ask chronic liver features when possible ## Context and risk ### Surgery, hernias, bowel disease, cancer, pregnancy ### Prior surgery raises adhesion risk, not proof ### Medicines cause ulcer, bleeding, dysmotility #### Review anti-inflammatories, antithrombotics, opioids ### Diet asked neutrally and specifically ### Family history: cancers, polyposis, inflammatory ### Social: sanitation, travel, housing, stoma care ## Immediate physiological assessment ### Airway risk from haematemesis or low consciousness ### Breathing, pulse, pressure, refill, mental state ### Seek shock, sepsis, bleeding, perforation, obstruction ### Normal early haemoglobin does not exclude major loss #### Plasma and red cells lost together ## General and abdominal examination ### Observe distress, wasting, pallor, jaundice ### Hands: clubbing, erythema, asterixis ### Chronic liver signs support context only ### Expose chest to groin with dignity ### Bowel sounds have limited accuracy ### Gentle palpation away from pain, watch face #### Voluntary guarding versus involuntary rigidity #### Rebound unneeded if irritation already shown #### Never press a suspected aneurysm forcefully ### Shifting dullness less sensitive than ultrasound ### Rectal examination only when it changes care ### Examine beyond the abdomen ## Baseline investigations ### Tests follow the syndrome ### Blood count, electrolytes, gas, liver tests ### Interpret trends and pretest probability #### Normal lactate misses early mesenteric ischaemia #### Mild lipase rise occurs outside pancreatitis #### Occult blood does not localise bleeding ### Stool tests for inflammatory, outbreak, travel cases ## Imaging and endoscopy ### Plain films: limited indications ### Negative erect chest film allows perforation ### Ultrasound for gallstones, biliary tree, ascites ### Computed tomography for obstruction, perforation ### Urgent angiography for bleeding or ischaemia ### Endoscopy sees, biopsies and treats #### Capsule may be retained at strictures #### Retrograde study mainly therapeutic ## Acute pain and surgical consultation ### Resuscitation and diagnosis proceed together ### Analgesia with repeated examination hides little ### Early surgery for time-sensitive disease ### Immediate escalation list #### Peritonism, free gas, strangulation, ischaemia #### Ruptured aneurysm, ectopic pregnancy, torsion ### Muted signs in frail, pregnant, immunosuppressed ### Reassessment after treatment is diagnosis