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Diagnosis of Chronic digestive diseases

Chronic digestive diseases Diagnosis: Book Excerpts

Diagnostic Tests for Chronic digestive diseases: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Chronic digestive diseases.


NAUSEA AND VOMITING: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is there a history of alcohol or drug ingestion? Alcohol and many drugs such as digitalis, aspirin, nonsteroidal anti-inflammatory agents, antihypertensives, and antibiotics may cause gastric irritation or gastritis.
  2. Is there fever? Fever may point to a localized abdominal condition such as acute cholecystitis or acute appendicitis, as well as a systemic condition such as tuberculosis, brucellosis, yellow fever, and other febrile illnesses.
  3. Is there abdominal pain? Abdominal pain suggests the possibility of acute cholecystitis, acute appendicitis, pyelonephritis, pancreatitis, renal calculus, and peritonitis.
  4. Is there an abdominal mass? The presence of an abdominal mass suggests pyloric or intestinal obstruction, a pancreatic neoplasm, acute cholecystitis, Crohn's disease, perinephric abscess, diverticulitis, and other abscesses and neoplasms.
  5. Is there vertigo? The clinician should remember that inner ear diseases such as Ménière's disease and labyrinthitis may be associated with vomiting, and sometimes the patient does not mention vertigo.
  6. Is there headache? Migraine, concussion, cerebral tumors or other space-occupying lesions, meningitis, and subarachnoid hemorrhage are associated with headaches, nausea, and vomiting.

DIAGNOSTIC WORKUP

The basic workup includes a CBC, sedimentation rate, urinalysis, urine drug screen, chemistry panel and electrolytes, serum amylase, arterial blood gases, stools for occult blood, chest x-ray, EKG, and flat plate of the abdomen. Acute onset of nausea and vomiting with ataxia requires an immediate CT scan of the brain to rule out a cerebellar hemorrhage. A pregnancy test should be routine in women of child-bearing age. If there is fever, febrile agglutinins and a heterophile antibody titer should be done. If there is an abdominal mass, a gallbladder ultrasound and intravenous pyelogram may need to be done. Isotope scanning with iminodiacetic acid derivatives is extremely useful to detect acute cholecystitis. If there is chronic vomiting and abdominal pain, the diagnosis can often be made with an upper GI series, small bowel series, or barium enema.

When there is persistent vomiting with abdominal pain, an exploratory laparotomy may need to be considered. The presence of an abdominal mass or suspected pancreatic or biliary disease merits consideration of a CT scan. However, before ordering expensive diagnostic tests, a general surgeon or gastroenterologist ought to be consulted. Laparoscopy, gastroscopy, esophagoscopy, duodenoscopy, and colonoscopy all need to be considered in the workup. Gastroparesis and intestinal pseudo-obstruction can be ruled out by radioisotope studies and manometry of the stomach and small intestine. Angiography is useful to diagnose mesenteric artery ischemia.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Nausea & Vomiting: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Central nausea/vomiting
    –Pregnancy (hyperemesis gravidarum)
    –Uremia
    –Hypercalcemia
    –Drugs (e.g., chemotherapy agents)
    –Carbon monoxide poisoning
  • Gastrointestinal disease
    –Infection (e.g., gastroenteritis, appendicitis, cholecystitis)
    –Obstruction (e.g., pyloric stenosis, small bowel obstruction, large bowel obstruction, gastroparesis, Ogilvie's syndrome)
    –Inflammation (e.g., pancreatitis, peptic ulcer disease)
    –Food poisoning
  • Toxic ingestions
    –Syrup of ipecac
    –Alcohol
    –Salicylates: Result in tachypnea, tinnitus,
  • and metabolic acidosis/respiratory alkalosis
    –Iron: Causes profound gastritis
    –Arsenic
  • Middle ear disease (e.g., Ménie're's disease, labyrinthitis, benign positional vertigo)
  • Post-tussive emesis (especially in children)
  • Motion sickness
  • CNS disease
    –Increased intracranial pressure due to brain tumor, CNS infection (e.g., meningitis, abscess), head trauma, hydrocephalus, subarachnoid hemorrhage, vestibular neuritis, or intracerebral hemorrhage
    –Migraine headache
  • Acute myocardial infarction (especially inferior MI)
  • Ovarian torsion
  • Testicular torsion
  • Malingering: Relatively common, but should be a diagnosis of exclusion until more serious causes are excluded
  • Intussusception: Classically causes colicky abdominal pain, vomiting, and currant jelly stools
  • Pyelonephritis or other abdominal process

Workup and Diagnosis

  • Complete history and physical examination is the most useful diagnostic aid
    –Neurologic examination looking for clues to CNS lesions
    –Ear examination to evaluate for middle ear disease
    –Ophthalmologic examination to evaluate for nystagmus in labyrinthitis or benign positional vertigo
    –Abdominal examination including stool guaiac to evaluate for GI pathology
  • Labs may include CBC, electrolytes, liver function tests, amylase, lipase, urinalysis, calcium, magnesium, salicylate level, hepatitis serologies, toxicology screen, and CSF analysis (for meningitis or bleeding)
  • ECG and cardiac enzymes may be indicated to evaluate for cardiac ischemia
  • Abdominal CT scan with oral and IV contrast if history and physical examination suggest abdominal pathology
  • Plain KUB X-rays may be indicated to evaluate for bowel obstruction or perforation
  • Abdomen/pelvic ultrasound is especially helpful in cases of lower abdominal pain in female patients or in suspected gallbladder disease
  • Endoscopy is indicated for suspected peptic ulcer disease
  • Head CT with and without contrast if CNS lesion is suspected

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Vomiting: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

  • Infections
    –Gastroenteritis is the most common cause among all pediatric age groups; may be viral, bacterial, or parasitic
    –Urinary tract infection/pyelonephritis
    –Sepsis
    –Meningitis
    –Viral hepatitis: e.g., Hepatitis A
    –Helicobacter pylori-related ulcer
  • Anatomic
    –Esophageal: Tracheoesophageal atresia, esophageal ring/web/stricture, achalasia
    –Gastric: Pyloric stenosis, volvulus
    –Small intestine: Duodenal atresia, malrotation, meconium ileus, duodenal hematoma, SMA syndrome, duplication, intussusception, hernia
    –Colon: Hirschprung, imperforate anus
  • Gastrointestinal
    –Gastroesophageal reflux disease
    –Allergy (e.g., celiac disease, milk protein)
    –Peptic ulcer disease
    –Appendicitis
    –Foreign body
    –Pancreatitis
    –Cholecystitis
    –Eosinophilic enteropathy
    –Pseudo-obstruction
  • Neurologic
    –Intracranial mass
    –Hydrocephalus
    –Pseudotumor cerebri
    –Migraines
  • Renal
    –Obstructive uropathy
    –Nephrolithiasis
    –Glomerulonephritis
    –Renal tubular acidosis
  • Toxins/drugs
    –Aspirin, theophylline, digoxin, lead
    –Chemotherapeutics
  • Pregnancy
  • Inborn errors of metabolism
  • Endocrine
    –Diabetic ketoacidosis
    –Adrenal insufficiency
    –Congenital adrenal hyperplasia
  • Respiratory
    –Pneumonia
    –Post-tussive

Workup and Diagnosis

  • History and physical crucial because of large differential
    • History
      –Duration, frequency, bilious material, abdominal pain, diarrhea, hematemesis, hematochezia, melena, headache, fever, dysuria, weight loss, urine output
      –Sick contacts, cough, rhinorrhea, neck stiffness
    • Birth history: Polyhydramnios, passage of meconium
    • Family history: Genetic disease, early childhood deaths
      • Physical exam
        –Vitals, weight, mucous membranes, nasal discharge, breath sounds, rashes, meningismus
        –Abdominal pain/distension, hepatosplenomegaly, abdominal masses, Murphy/obturator/psoas sign
        –Skin turgor, capillary refill
        –Neuro exam including funduscopy for papilledema
      • Labs: Initial screen based on physical exam
        –Consider electrolytes, LFTs, amylase, lipase
        –U/A and culture; lactate and pyruvate
        –Serum amino acids/urine organic acids, ammonia for metabolic diseases; blood gas for acidosis
        –CBC for infections, lumbar puncture
    • KUB or obstruction series as initial X-ray
    • Contrast study with upper GI series with or without small bowel follow-through or BE for anatomic problem
    • Abdominal ultrasound for pyloric stenosis
    • Head imaging including CT/MRI
    • Upper endoscopy and colonoscopy for mucosal inflammation

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Vomiting – Projectile: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

  • Anatomic/obstructive
    –Pyloric stenosis: Classic description of progressive projectile vomiting; more common among first-born males and typically presents in weeks 4–8 of life; may see hypochloremic, hypokalemic metabolic alkalosis
    –Hiatal hernia
    –Pyloric atresia
    –Gastric volvulus
    –Gastric outlet obstruction due to chronic granulomatous disease, peptic ulceration near the pyloris, or gastric tumors
    –Duodenal web
    –Duodenal atresia
    –Duodenal stenosis
    –Superior mesenteric artery syndrome: Typically due to weight loss, postsurgical correction of scoliosis, or immobilization with body cast
    –Urinary tract obstruction: Ureteropelvic junction obstruction (abdominal pain and vomiting known as Dietl crisis); nephrolithiasis
    • Inflammatory
      –Gastroesophageal reflux disease
      –Peptic ulcer disease
      –Pyelonephritis
      –Meningitis
      –Encephalitis
      –Eosinophilic enteropathy
    • Central nervous system
      –Brain tumor
      –Trauma
      –Lead encephalopathy
      –Acute intracranial hemorrhage
      –Hydrocephalus
    • Metabolic/endocrine
      –Congenital adrenal hyperplasia
      –Hypercalcemia
      –Wolman disease
      –Phenylketonuria

    Workup and Diagnosis

    • Differentiating vomiting from projectile vomiting is often difficult when obtaining history
    • History: Age at presentation, frequency and amount of emesis, time after feeding until emesis, bilious or nonbilious, hematemesis, weight loss, fever, diarrhea, abdominal pain, melena, hematochezia, activity level, dysuria, menses, pica, recent trauma
    • Birth history: Meconium in nursery, oligohydramnios, polyhydramnios, newborn screen, birth weight
    • Family history: First born
    • Diet history: Formula intolerance
    • Surgical history: Previous abdominal surgeries
    • Social history: House built before 1965 (lead paint)
    • Physical exam: Weight, height, head cirumference, vital signs, mucous membranes, fontanelle, papilledema, equal breath sounds, abdominal distension, abdominal mass (palpable olive in pyloric stenosis), bowel sounds, skin turgor, capillary refill, reflexes, tone, strength
    • Chemistry panel with focus on chloride, CO2, potassium, calcium; CBC with differential for signs of infection, consider urine analysis and culture
    • Abdominal films for obstruction
    • Ultrasound a sensitive and specific method for pyloric stenosis; findings of elongation of pyloric channel and thickening of pyloric muscle; U/S for pelvic obstruction
    • Upper GI series for malrotation, atresia, superior mesenteric artery
    • CT scan for head or abdominal mass

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    NAUSEA AND VOMITING: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The association of other symptoms and signs is essential in pinpointing the diagnosis of vomiting. For example, vomiting with tinnitus and vertigo suggests Ménière disease, whereas vomiting with hematemesis suggests gastritis, esophageal varices, and gastric ulcers. The laboratory workup should include a flat plate of the abdomen, upper GI series, esophagram, cholecystogram, gastric analysis, serum electrolytes, and amylase and lipase levels. Stools for occult blood, ova, and parasites are usually indicated. Gastroscopy and esophagoscopy are often indicated in the acute case, but an exploratory laparotomy should not be delayed if the patient’s condition is deteriorating and pancreatitis has been excluded.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Bowel sounds, hyperactive: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    If you've ruled out life-threatening conditions, obtain a detailed medical and surgical history. Ask the patient if he has had a hernia or abdominal surgery because these may cause mechanical intestinal obstruction. Does he have a history of inflammatory bowel disease? Also, ask about recent eruptions of gastroenteritis among family members, friends, or coworkers. If the patient has traveled recently, even within the United States, was he aware of any endemic illnesses?

    In addition, determine whether stress may have contributed to the patient's problem. Ask about food allergies and recent ingestion of unusual foods or fluids. Check for fever, which suggests infection. Having already auscultated, now gently inspect, percuss, and palpate the abdomen.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Vomiting: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask your patient to describe the onset, duration, and intensity of his vomiting. What started the vomiting? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and causes.) Explore any associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel habits or stools, excessive belching or flatus, and bloating or fullness.

    Obtain a medical history, noting GI, endocrine, and metabolic disorders; recent infections; and cancer, including chemotherapy or radiation therapy. Ask about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant. Ask which contraceptive method she’s using.

    Inspect the abdomen for distention, and auscultate for bowel sounds and bruits. Palpate for rigidity and tenderness, and test for rebound tenderness. Next, palpate and percuss the liver for enlargement. Assess other body systems as appropriate.

    During the examination, keep in mind that projectile vomiting unaccompanied by nausea may indicate increased intracranial pressure, a life-threatening emergency. If this occurs in a patient with CNS injury, you should quickly check his vital signs. Be alert for widened pulse pressure or bradycardia.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Bowel sounds, hyperactive: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If you’ve ruled out life-threatening conditions, obtain a detailed medical and surgical history. Ask the patient if he has had a hernia or abdominal surgery because these may cause mechanical intestinal obstruction. Does he have a history of inflammatory bowel disease? Also, ask about recent episodes of gastroenteritis among family members, friends, or coworkers. If the patient has traveled recently, even within the United States, was he aware of any endemic illnesses?

    In addition, determine whether stress may have contributed to the patient’s problem. Ask about food allergies and recent ingestion of unusual foods or fluids. Check for fever, which suggests infection. Having already auscultated, now gently inspect, percuss, and palpate the abdomen.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Vomiting: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask your patient to describe the onset, duration, and intensity of his vomiting. What started it? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and causes.) Explore any associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel elimination patterns or the appearance of stools, excessive belching or flatus, and bloating or fullness.

    Obtain a medical history, noting GI, endocrine, and metabolic disorders; recent infections; and cancer, including chemotherapy or radiation therapy. Ask about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant and which contraceptive method she uses.

    Inspect the abdomen for distention, and auscultate for bowel sounds and bruits. Palpate for rigidity and tenderness, and test for rebound tenderness. Next, palpate and percuss the liver for enlargement. Assess other body systems as appropriate.

    During the examination, keep in mind that projectile vomiting unaccompanied by nausea may indicate increased intracranial pressure, a life-threatening emergency. If this occurs in a patient with a CNS injury, quickly check his vital signs. Be alert for widened pulse pressure or bradycardia.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Nausea and Vomiting: History.
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    As is usually the case in clinical practice, most diagnoses will be made by history and confirmed by physical examination and laboratory studies. Key points in the history include the following:

    A. Are the symptoms acute, chronic, or recurrent?

    B. If vomiting is the predominant feature, consider GI infection, reflux, gastritis, or ulcer.

    C. Nausea as the predominant feature often results from systemic problems.

    D. Is there a history of travel, drinking unsafe water, or eating unusual or uncooked food?

    E. Is there a history of fevers or chills (Chapter 2.6.)?

     F. Are general systemic symptoms or signs such as edema, discolored urine or jaundice, fatigue, weight loss or anorexia, headache, or blurred vision present?

     G. Are psychiatric symptoms present?

    H. Is the patient taking any medications?

    I. Is diarrhea present?

     J. Is there abdominal pain? The presence of abdominal pain raises some important and potentially serious possibilities:

    1. Common problems presenting with abdominal pain and vomiting include cholecystitis, appendicitis, gastritis or ulcer, hepatitis, small bowel obstruction, inferior myocardial infarction or ischemia, renal colic, peritonitis, pancreatitis, food poisoning, and complications of pregnancy.

     2. Uncommon problems presenting with abdominal pain and vomiting include diabetic ketoacidosis, drug withdrawal, uremia, and vasculitis or abdominal migraine.

     3. Rare problems presenting with abdominal pain and vomiting include porphyria, lead intoxication, adrenal insufficiency, hyperlipidemia, abdominal epilepsy, glaucoma, hypercalcemia, and acute hemolysis.

    Physical examination.

     A directed physical examination is dictated by the findings on history, but the following are areas of key importance:

    A. Vital signs. Focus on presence of fever, pulse, and blood pressure to assess hydration, and respiratory rate to look for acidosis-related hyperventilation.

     B. Skin, eyes, mucous membranes. Look for dehydration and signs of jaundice.

     C. Signs of systemic infection. Pay special attention to examining the lung and the costovertebral angle for tenderness.

     D. A detailed abdominal examination should include inspection, auscultation, palpation, percussion, areas of tenderness, rebound, guarding, hepatomegaly, Murphy’s sign, stool for occult blood, and bimanual pelvic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

    Nausea/Vomiting: Differential Overview
    (Field Guide to Bedside Diagnosis)

    Presenting Symptom

    ❑ Gastroesophageal reflux

    ❑ Pregnancy

    ❑ Psychogenic

    ❑ Bulimia

    ❑ Rumination

    ❑ Diabetic ketoacidosis

    ❑ Hepatitis

    ❑ Inferior myocardial infarction

    ❑ Uremia

    ❑ Adrenal insufficiency

    With Abdominal Pain

    ❑ Viral gastroenteritis

    ❑ Food poisoning

    ❑ Peptic ulcer disease

    ❑ Renal colic

    ❑ Pancreatitis

    ❑ Pyelonephritis

    ❑ Appendicitis

    ❑ Cholecystitis

    ❑ Small bowel obstruction

    ❑ Peritonitis

    With Neurologic Signs

    ❑ Migraine headache

    ❑ Vestibular disturbance

    ❑ Autonomic dysfunction

    ❑ Increased intracranial pressure

    ❑ Hypercalcemia

    ❑ Cerebellar hemorrhage

    Diagnostic Approach

    Neurological vomiting may be projectile (forceful emesis without prior nausea), positional, or associated with other neurological signs. Central vomiting (chemoreceptor trigger zone stimulation, usually caused by toxins) is alleviated by antidopaminergic medications, which do not work well when treating nausea due to mechanical causes such as obstruction.

    Early morning nausea suggests pregnancy or metabolic causes (e.g., uremia). Vomiting of a large amount of undigested food 4 to 6 hours after eating is consistent with gastric retention resulting from pyloric obstruction
    or gastroparesis or to esophageal disorders such as achalasia or Zencker diverticulum. Feculent vomiting suggests intestinal obstruction or gastrocolic fistula.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Bowel sounds, hyperactive: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Determine if there’s a history of hernia or abdominal surgery because these may cause mechanical intestinal obstruction. Determine if there’s a history of IBD, eruptions of gastroenteritis among family members, friends, or coworkers. Ask if the patient has traveled recently, even within the United States.

    In addition, determine whether stress may have contributed to the patient’s problem. Ask about food allergies and recent ingestion of unusual foods or fluids.Obtain a full medication history, including
    over-the-counter medications.

    ALERT: Homosexual males who report acute diarrhea and exhibit negative fecal ova and parasite cultures may be infected with chlamydial proctitis not associated with lymphogranuloma venereum. Because rectal cultures will probably be negative, treatment with tetracycline is appropriate.

    Physical examination

    Check for fever, which suggests infection. Complete a full GI assessment by inspecting abdominal contour. Stoop at the recumbent patient’s side and then at the foot of his bed to detect localized or generalized distention. Auscultate the abdomen and note bowel sounds. Percuss and palpate the abdomen gently. Palpate for abdominal rigidity and guarding, which suggest peritoneal irritation that can lead to paralytic ileus.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Vomiting: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Ask the patient to describe the onset, duration, and intensity of his vomiting. What started the vomiting? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and causes.) Explore associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel habits or stools, excessive belching or flatus, and bloating or fullness.

    Obtain a medical history, noting GI, endocrine, and metabolic disorders; recent infections; and cancer, including chemotherapy or radiation therapy. Ask about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant. Ask which contraceptive method she’s using.

    Physical examination

    Inspect the abdomen for distention, and auscultate for bowel sounds and bruits. Palpate for rigidity and tenderness, and test for rebound tenderness. Next, palpate and percuss the liver for enlargement. Assess other body systems as appropriate.

    During the examination, keep in mind that projectile vomiting unaccompanied by nausea may indicate increased intracranial pressure (ICP), a life-threatening emergency. If this occurs in a patient with a CNS injury, you should quickly check his vital signs. Stay alert for widened pulse pressure or bradycardia.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Bowel sounds, hyperactive: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    If you’ve ruled out life-threatening conditions, obtain a detailed medical and surgical history. Ask the patient if he has had a hernia or abdominal surgery because these may cause mechanical intestinal obstruction. Does he have a history of inflammatory bowel disease? Also, ask about recent eruptions of gastroenteritis among family members, friends, or coworkers. If the patient has traveled recently, even within the United States, was he aware of any endemic illnesses?

    In addition, determine whether stress may have contributed to the patient’s problem. Ask about food allergies and recent ingestion of unusual foods or fluids.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Vomiting: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask your patient to describe the onset, duration, and intensity of his vomiting. What started the vomiting? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and causes, page 700.) Explore any associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel habits or stools, excessive belching or flatus, and bloating or fullness.

    Obtain a medical history, noting GI, endocrine, and metabolic disorders; recent infections; and cancer, including chemotherapy or radiation therapy. Ask about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant. Ask which contraceptive method she’s using.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Regurgitation and Vomiting: Clinical Features and Diagnosis: Regurgitation
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Normal Variations

  • In infants,milk may flow from mouth during or after feeding with little effortor distress.
  • Common causes include overfeeding,air swallowed during feeding, crying, or coughing.
  • Physical exam is normal and weightgain is adequate. History and physical exam are diagnostic.

    • Gastroesophageal Reflux

  • Is the spontaneouspassage of stomach contents into esophagus.
  • Common finding in many infants. Maybegin by a few weeks of age and usually resolves by 8–12mos of age. Infant is otherwise asymptomatic and has normal weightgain. No testing is required in this clinical circumstance.
  • Gastroesophageal reflux disease refersto infants with regurgitation and vomiting associated with poorweight gain; respiratory symptoms (e.g., wheezing, hoarseness, orapnea); or esophagitis. Upper GI series is valuable to exclude anyanatomic abnormality. Esophageal pH probe study can quantitate frequencyand duration of acid reflux episodes. Endoscopy with biopsy shouldbe performed if esophagitis is suspected.

    • Esophageal Disorders

    Congenital Anomalies

    Esophageal Atresia with or without Tracheoesophageal Fistula

  • Esophagealatresia usually exists with distal tracheoesophageal fistula. Uppersegment of esophagus ends in blind pouch and lower segment communicateswith trachea.
  • Maternal history of polyhydramniosis common.
  • Drooling, choking, and regurgitationoccur with first feeding.
  • Opaque nasal catheter that fails topass into stomach and remains curled up in proximal esophagus establishesdiagnosis. Air in stomach on chest radiograph indicates presenceof tracheoesophageal fistula. If diagnosis is uncertain, injectionof small amount of contrast material into upper esophagus with fluoroscopyis confirmatory.

    • Esophageal Stenosis

  • Usuallyoccurs in middle third of esophagus.
  • Regurgitation and poor weight gainare prominent symptoms.
  • Contrast esophagram is diagnostic.

    • Esophageal Web

  • Mucosalmembrane that usually occurs in upper esophagus or at junction between middleand lower third of esophagus.
  • Obstruction may be complete and causeregurgitation soon after birth.
  • Diagnosis may be confirmed by esophagramor endoscopy.

    • Duplication

  • Duplicationsof esophagus are cystic or tubular structures that can compressesophagus, causing regurgitation. Some duplications contain gastricmucosa, which may produce GI bleeding.
  • Combination of tests, including chestradiography, upper GI radiographic series, and chest CT or MRI,is diagnostic.

    • Foreign Body

  • Esophagealforeign bodies usually cause obstruction at level of cricopharyngeusmuscle or just above lower esophageal sphincter.
  • Choking, coughing, dysphagia, regurgitation,and vomiting may occur. If foreign body is radiopaque, it may beseen on chest radiograph. Otherwise, filling defect is usually seenon esophagram.
  • Diagnosis may be confirmed by endoscopy.

    • Stricture

  • Usuallydue to long-standing reflux esophagitis but also may be due to causticingestion.
  • Usual manifestations are dysphagia,regurgitation, and vomiting.
  • Contrast esophagraphy or endoscopyis diagnostic.

    • Hiatal Hernia

  • Herniationof portion of stomach into thorax.
  • Usually is congenital and often isassociated with gastroesophageal reflux.
  • Although regurgitation, vomiting, andepigastric pain may occur, it can be asymptomatic.
  • Upper GI radiographic series is diagnostic.

    • Rumination

  • Regurgitationof already ingested food from stomach and esophagus into mouth, whereit is rechewed and swallowed or spit out.
  • Primarily occurs in 2 populations:developmentally impaired young children as self-stimulation behaviorand adolescents with significant psychological stress. Younger childrenhave minimal vomiting, whereas adolescents have significant vomiting.
  • pH probe shows resolution of esophagealacidification during sleep.

    • Diagnostic Approach: Regurgitation

  • In infantwith regurgitation who is otherwise well and gaining weight, mostlikely diagnosis is normal variation or mild gastroesophageal reflux.
  • Persistent regurgitation with poorweight gain, respiratory symptoms, or symptoms suggesting esophagitisrequires investigation.
  • Upper GI radiographic series excludesother causes of esophageal obstruction. Most reliable test for gastroesophagealreflux is esophageal pH monitoring. Endoscopy with biopsy can confirmdiagnosis of esophagitis.
  • Other investigations depend on history,physical exam, and results of the above studies.

    • » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Bowel sounds, hyperactive: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If you've ruled out life-threatening conditions, obtain a detailed medical and surgical history. Ask the patient if he has had a hernia or abdominal surgery because these may cause mechanical intestinal obstruction. Does he have a history of inflammatory bowel disease? Ask about recent eruptions of gastroenteritis among family members, friends, or coworkers. If the patient has traveled recently, even within the United States, was he aware of any endemic illnesses?

    In addition, determine whether stress may have contributed to the patient's problem. Ask about food allergies and recent ingestion of unusual foods or fluids. Check for fever, which suggests infection. Having already auscultated, now gently inspect, percuss, and palpate the abdomen.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Vomiting: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask your patient to describe the onset, duration, and intensity of his vomiting. What started the vomiting? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and causes.) Explore associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel habits or stools, excessive belching or flatus, and bloating or fullness.

    Obtain a medical history, noting GI, endocrine, and metabolic disorders; recent infections; and cancer, including chemotherapy or radiation therapy. Ask the patient about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant or which contraceptive method she's using.

    Inspect the patient's abdomen for distention and localized bulging, and auscultate for bowel sounds and bruits. Palpate for rigidity and tenderness and test for rebound tenderness. Palpate and percuss the liver for enlargement. Assess the patient's other body systems as appropriate.

    During the examination, keep in mind that projectile vomiting unaccompanied by nausea may be an indication of increased intracranial pressure, a life-threatening emergency. If this occurs in a patient with CNS injury, you should quickly check his vital signs. Be alert for widened pulse pressure or bradycardia.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    NAUSEA AND VOMITING: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The association of other symptoms and signs is essential in pinpointing the diagnosis of vomiting. For example, vomiting with tinnitus and vertigo suggests Ménière disease, whereas vomiting with hematemesis suggests gastritis, esophageal varices, and gastric ulcers. The laboratory workup should include a flat plate of the abdomen, upper GI series, esophagram, cholecystogram, gastric analysis, serum electrolytes, and amylase and lipase levels. Stools for occult blood, ova, and parasites are usually indicated. Gastroscopy and esophagoscopy are often indicated in the acute case, but an exploratory laparotomy should not be delayed if the patient’s condition is deteriorating and pancreatitis has been excluded.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007


     » Next page: Misdiagnosis of Chronic digestive diseases

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