Evaluation of the Patient with Gastrointestinal Disease
Evaluation of the patient with GI disease begins with a careful history and physical examination. Subsequent investigation with a variety of tools designed to test the structure or function of the gut is indicated in selected cases. Some patients exhibit normal findings on diagnostic testing. In these individuals, validated symptom profiles are employed for confident diagnosis of a functional bowel disorder.
History
1. Symptom timing1) Short duration : acute infection, toxin exposure, or abrupt inflammation or ischemia.
2) Long-standing symptoms :
underlying chronic inflammatory or neoplastic condition or a functional bowel disorder.
3) After meal digestion
Worseningby mechanical obstruction, ischemia, IBD, and functional bowel disorders
Relieving by ulcer
2. Symptom relation to other factors
ex. prior abdominal surgery, loose stools after gastrectomy or gallbladder
3. Symptom onset
ex. after travel
4. Medications or food supplements
5. Sexual history may raise concern for sexually transmitted diseases or immunodeficiency.
Rome criteria.
When tested against findings of structural investigations,
the Rome criteria exhibit diagnostic specificities >90% for many of the functional bowel disorders.
- Past History
- Family Hxistory
-Reviewof system
General
generalized weakness(-)
fever/chilling/sweating(-/-/-)
poor oral intake/irritability(-/-)
Respiratory
dyspnea/cough/sputum/rhinorrhea(-/-/-/-)
sore throat/hoarseness(-/-)
Cardiovascular
chest pain/cyanosis (-/-)
Gastrointestinal
abdominal pain(-)
nausea/vomiting(-/-)
constipation/diarrhea(-/-)
Genitourinary
dysuria/frequency/nocturia(-/-/-)
hematuria/oliguria (-/-)
Extremities
LOM(-)
Physical Examination
1. Vital signs : BT ℃ HR 회/min RR 회/min
2. P/Ex. : Inspection -> Auscultation -> Percussion -> Palpation
General appearance
Acutely ill looking appearance
Head & Neck
Normocephaly
No cervical lymphadenopathy/No neck stiffness
Eyes
Isocoria c PPLR(++/++)
Non-anemic conjunctvae/Anicteric sclerae
ENT
Dysphagia(-)
Pharyngeal injection/Tonsilar enlargement (-/-)
Post. Nasal drip(-)
Chest
Clear breathing sound without rale
Regular heart beat without murmur
Abdomen
Soft & flat / Hard & distension
Bowel sound : Hypoactive / Hyperactive / Loss
Td/RTd(-/-) : Location
Guarding(-)
No organomegaly/No palpable mass
Rectal exam. : DRE(-)
Lower Extremities
Grossly free, No pitting edema
Peripheral neuropathy(-)
Skin: No rash
Tools for Patient Evaluation
1. Laboratory testing
1) CBC : WBC, RBC, PLT
2) Biologic chemistry : electrolytes, acid-base imbalance, BUN/Cr, LFT, amylase, lipase
3) Hormonal test : TFT
4) Pregnancy test
5) Serologic test
are available to screen for celiac disease, IBD, and rheumatologic diseases or scleroderma.
6) Tumor marker test : CEA, CA 19-9, alpha-fetoprotein...
7) Body fluid : Ascites, CSF
8) Urinalysis
are screened for carcinoid, porphyria, and heavy metal intoxication.
2. Luminal contents
1) Esophageal pH testing
2) Gastric acdi quantifying
3)Duodenal aspiration
4) Pancreatic juice
5) Stool samples
6) Fecal fat
7) Laxative screening
3.Endoscopy
1) Upper endoscopy : esophagus, stomach, and duodenum
2) Colonoscopy : colon and distal ileum.
3) Sigmoidoscopy : from colon up to the splenic flexure
4) Enteroscopy, capsule endoscopy, or the novel technique of double-balloon enteroscopy
5) Endoscopic retrograde cholangiopancreaticography (ERCP) : pancreatic and biliary disease.
6) Endoscopic ultrasound
evaluate the extent of disease in GI malignancy as well as exclude choledocholithiasis
evaluate pancreatitis, drain pancreatic pseudocysts, and assess anal continuity.
4. Radiography/Nuclear testing
1) Contrast radiography(using Barium orGastrographine): transit & pelvic floor dysfunction
Barium swallowing test :
for evaluation of dysphagia to exclude subtle rings or strictures and assess for achalasia
Small-bowel contrast test : diagnoses intestinal tumors and Crohn's ileitis.
Contrast enemas : when colonoscopy is unsuccessful or contraindicated.
2) Ultrasound : evaluate regions not accessible by endoscopy or contrast studies
-> mass, fluid collections, organ enlargement, and in the case of ultrasound gallstones
ex. including the liver, pancreas, gallbladder, kidneys, and retroperitoneum.
3) CT and MR colonography
4) Angiography
5) Positron emission tomography(PET)
6) Scintigraphy : evaluate structural abnormalities and quantifies luminal transit.
7) Radionuclide bleeding scans :localize bleeding sites in patients with brisk hemorrhage
8) Radiolabeled leukocyte scans : search for intraabdominal abscesses not visualized on CT.
9) Biliary scintigraphy
5.Histopathologic testing
1) Gut mucosal biopsies : evaluate for inflammatory, infectious, and neoplastic disease.
2) Deep rectal biopsies : assist with diagnosis of Hirschsprung's disease or amyloid.
3) Liver biopsy
1) Manometry
Esophaeal manometry
Small-intestinal manometry
Biliary manometry : for sphincter of Oddi dysfunction
Anorectal manometry c ballon expulsion :
unexplained incontinence or constipation from outlet dysfunction
2) Electrogastrography / Electromyography
3) Gastric acid and pancreatic function testing
4) Breath test & Capsule techniques :
quantifying gastric emptying Anorectal manometry with balloon expulsion