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The Semiology of the Stomach and Duodenum
ARE YOU READY? WE TALK ABOUT
THE SEMIOLOGY OF THE STOMACH AND DUODENUM
C H A P T E R
4 The Semiology of the Stomach and Duodenum O U T L I N E 4.1 Questionnaire
4.2 Symptoms 295 4.2.1 Epigastric Pain 296 4.2.2 BelchingdEructation 299 4.2.3 Regurgitation 299 4.2.4 HeartburndPyrosis 299 4.2.5 Vomiting 299 4.2.6 Hematemesis 304 4.2.7 Melenadblack stoolsdupper bleeding 305 4.2.8 Hematemesis and melena represent the main signs of upper bleeding 306 4.3 The Objective General Examination 4.3.1 “Squat” Attitude 4.3.2 Muscle Contracture 4.3.3 Zygomatic Face 4.3.4 Paleness 4.3.5 Emaciation
Medical Semiology Guide of the Digestive System https://doi.org/10.1016/B978-0-12-819636-6.00004-7
4.3.6 Sign of virchoweTroisier
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4.4 The Objective Examination of the Stomach 4.4.1 The Inspection 4.4.2 The Palpation 4.4.3 Percussion 4.4.4 Auscultation
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4.5 The Complementary Investigations of the Stomach 315 4.5.1 The Radiological ExaminationdBarium Swallow Test; Morphological Examination of the Stomach Barium SwallowdNiche ImagedRecess in a Wall 315 4.5.2 The Upper EndoscopydGastroscopy 320 4.6 Clinical Case of the Stomach 4.6.1 Clinical Case
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4.2 Symptoms
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4.1 Questionnaire 1. Where did the pain start? Were you feeling pain in the first instance? I feel pain in the epigastric areadepigastric pain. This is the location. 2. What does the pain feel like? Can you compare it with something? I feel the pain like a burning sensation. This is the characteristic. 3. How long has the pain been going on? I have been feeling the pain for 15 min. This is the duration. 4. Where did you feel the pain radiate, starting from the epigastric area? After the pain started in the epigastric area, I felt the pain in the back. This is the irradiation. I feel the pain only in the epigastric area. This is without irradiation. 5. Under what conditions does the epigastric pain appear? I feel the epigastric pain when my stomach is empty before eating. I feel the epigastric pain after eating. These are the conditions of appearance. The correlation with eating is very important when we characterize epigastric pain, because we can suspect directly the diagnosis of gastric ulcer or duodenal ulcer if we are careful in how we ask the patient, and it depends on what answer we receive. For example, if the epigastric pain appears before eating, this is suggestive of duodenal ulcer; and if the epigastric pain appears after eating, this is very suggestive of gastric ulcer. 6. Under what conditions does the epigastric pain disappear? What ameliorates the epigastric pain? If I eat something, it stops my epigastric pain. This is typical of duodenal ulcer. If I drink a cup of milk and a few biscuits, it stops my epigastric pain. Also, alkaline substances stop my epigastric pain. This is typical of bothd epigastric and duodenal ulcer. These are the conditions of extinction. 7. What other symptoms do you feel at the same time with the epigastric pain? I feel nausea. This is the accompanying symptom. I do not feel anything else, only epigastric pain. This is without symptoms of accompaniment. I feel nausea and dizziness. These are the accompanying symptoms.
4.2 Symptoms The main symptoms of stomach diseases are very important because these attract the attention of the physician to the pathology of the stomach. If we recognize these symptoms in a patient, we must suspect a stomach disease. The most important symptoms are: • • • • • •
Epigastric pain Belching or eructation Regurgitation Heartburn (pyrosis) Vomiting Hematemesis
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4.2.1 Epigastric Pain Epigastric pain is typically located in the epigastric area and very suggestive of stomach disease, but it can also suggest acute pancreatitis or an acute posterioreinferior myocardial infarction (heart attack). 4.2.1.1 Correlation with alimentation The very important characteristic of epigastric pain in stomach disease is that this is in correlation with alimentation. 4.2.1.1.1 Gastric ulcer e Epigatric pain - After Eating Epigastric pain in gastric ulcer appears after alimentation. This can possibly appear immediately after a person eats or after 1e2 h or even later than that, after 3e4 h. The most important idea is that all the time in gastric ulcer, the pain appears after eating. For this reason the patient avoids eating to not start the epigastric pain and suffers weight loss. It is possible to suspect the location of a gastric ulcer in correlation with time and when the pain starts after eating: immediately after alimentation is suggestive of an ulcer around the cardia and after 1e2 h suggests postoperative peptic ulcer and later, at 3e4 h, suggests pyloric ulcer. In the following image we can see the correlation of pain after alimentation. After EatingdI Have Epigastric Pain
In the image above a red lightning bolt indicates the area of the abdomen where the patient with stomach disease feels pain, the epigastric area.
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4.2.1.1.2 Duodenal ulcer e Epigastric pain - Before Eating In duodenal ulcer the epigastric pain appears before eating, when the stomach is empty. In the following image this phenomenon is illustrated. I didn’t eat anything in the morning and at lunch and I feel intense epigastric pain. What is wrong with me?
Epigastric pain before eatingdsuggestive of duodenal ulcer
Also, when epigastric pain appears during the night or after the middle of the night, when the stomach is empty, and it wakes the patient up from sleep, this situation is again typical of duodenal ulcer. The phenomenon is illustrated in the following image. I do not eat anything and I feel sudden epigastric pain in the middle of the night. This is also typical of duodenal ulcer, because in this period the stomach is empty.
4.2.1.1.3 Duodenal ulcer - Epigastric pain during the night
Epigastric pain during the nightdtypical of duodenal ulcer
Usually if the patient eats a few biscuits and drinks a cup of milk, the epigastric pain ameliorates or stops. Because the pain stops after eating in duodenal ulcer, these categories of patients eat frequently to stop the pain; and for this reason these patients gain weight and can become obese, different from the patients with gastric ulcer, who lose weight, because the eating develops pain and they avoid eating. 4.2.1.1.4 Small periodicity Because the patient suffers every day and at every meal with this correlation between epigastric pain and alimentation, this phenomenon is of a small periodicity. If these incidences occur for a period of a few weeks during spring and autumn, this phenomenon is of a large periodicity. 4.2.1.2 Big periodicity Usually, if the ulcer is not complicated, the epigastric pain does not irradiate. When the patient feels irradiation of the pain, this suggests a complication of the ulcer. For example, if the pain irradiates into the back, this is suggestive of a penetration of the ulcer to the pancreas. The first time a patient comes in to the physician with epigastric pain, we must ask the patient these most important questions, and in this way we can differentiate the most important characteristics of the pain.
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4.2.2 BelchingdEructation The definition of belching or eructation is the removal of gas from the stomach through the mouth. If a person eats quickly and swallows airdaerophagiadand then feels the need to eliminate gases through the mouth, eructation occurs. In this situation the eructation does not have any smell. In pyloric stenosis, because the food is not evacuated normally from the stomach and remains there for a long period of time and stagnates, a fermentative process occurs; and because of this, when a patient with pyloric stenosis develops eructation, it will be with a bad smell like “rotten eggs.”
4.2.3 Regurgitation The definition of regurgitation is the returning of food from the stomach into the mouth, occurring typically in hiatal hernia. Gastric regurgitation occurs with a sour taste and acidic sensation.
4.2.4 HeartburndPyrosis Pyrosis is the heartburn sensation and is typical in gastric and duodenal ulcer as well as in the esophageal diseases. The patient feels the epigastric pain sometimes like a burning sensation. This is typical pyrosis and sometimes can substitute for the pain. Alkaline substances can stop this, or ingestion of milk because it is alkaline, and biscuits stop pyrosis. In gastroesophageal ebb the patient feels pyrosis in the retrosternal area and develops reflux esophagitis.
4.2.5 Vomiting The definition of vomiting is the elimination of the contents of the stomach and bowel through the mouth. Usually vomiting is preceded by nausea, but rarely it is possible to be without nausea in central vomitingd“vomiting jet.” There are two major types of vomiting: central and peripheral. 4.2.5.1 Central Vomiting Central vomiting is typically without nausea and in a jet and is specific for all the diseases that develop intracranial hypertension. This situation is specific to hypertensive patients, who can develop hypertensive encephalopathy, cerebral edema, and intracranial hypertension. The most common example is in stroke attackdbleeding stroke attack. The situation must be recognized as early as possible and not be confused with peripheral vomiting such as in digestive diseases, because in this case, without a correct therapy in time, the patient can develop an unexpected deep coma and sudden death. Another important cause of central vomiting is trauma to the head, when the patient loses consciousness for a period of time and develops a hematoma of the brain. Because this develops intracranial hypertension it represents a cause of central vomiting, which appears suddenly, without nausea, and in a jet. A tumor of the brain or other solid masses inside the brain can also develop intracranial hypertension and central vomiting. Of course, in all these situations, a CT scan of the brain must be performed immediately. The main important idea is not to confuse in medical practice central vomiting that has neurological causes with the totally different protocol management therapy for peripheral vomiting with other characteristics that suggest digestive disease. INTRACRANIAL HYPERTENSIONdCENTRAL VOMITING
INTRACRANIAN HYPERTENSION
CENTRAL VOMITTING
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4.2.5.2 Peripheral Vomiting Peripheral vomiting is the most common type of vomiting in medical practice. The patient feels nausea before vomiting, and the causes of this type represent many digestive diseases such as stomach, gallbladder, liver, pancreas, small bowel, enlarged bowel, peritoneal irritation, and annexitis in women. In these conditions vomiting appears as a reflex after causes from the digestive tract or peritoneum that stimulate the vomiting center. There are various examples of diseases that can develop peripheral vomiting in medical practice, such as gastritis, pyloric stenosis, gastric cancer, acute viral hepatitis, food poisoning, acute pancreatitis, occlusion of the small bowel or enlarged bowel, enteritis, gastroenteritis, acute peritonitis, metroanexitis, pregnancy, renal colic, and so on. DIGESTIVE DISEASESdPERIPHERAL VOMITING
DIGESTIVE DISEASES
PERIPHERAL VOMITTING
The semiologic analysis of vomiting follows these important characteristics: 4.2.5.2.1 Frequency FrequencydHow often does vomiting occur? How many times per day? It can occur occasionally, for example, when a person smells a bad odor, or repeatedly, in pyloric stenosis, or very oftendthe patient feels that he or she cannot stop vomiting, in pregnancy, hyperemesis, or severe intoxication with a toxic substance, such as lead or others. 4.2.5.2.2 Timing and rhythm Period: the time of day or night and the relationship with fooddIn what period of day does vomiting occur? If vomiting occurs later than two hours after eating, this suggests pyloric stenosis; in the morning before eating is typical of alcoholic people, chronic ethylic patients, or in pregnancy; in neurosis the patient commonly presents with vomiting during lunch; and vomiting during the night occurs in duodenal ulcer. 4.2.5.2.3 Volume VolumedIn pyloric stenosis, the volume of vomiting is increased because incompletely evacuated food remains inside the stomach for many days; and in hysteria and pregnancy, the volume is small. 4.2.5.2.4 The smell The smelldIt could be like feces in an occlusion of the bowel, rancid in pyloric stenosis, or acidic in hyperacidity. 4.2.5.2.5 Vomiting content Vomit contentdThe contents could include undigested food, which appears typically in pyloric stenosis and also in the morning before eating when the stomach normally must be empty. A quantity of bile is present in almost every vomiting because of the duodenal reflux, but in pyloric stenosis it is absent.
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If the vomiting is green like leeks, this is typical in peritonitis. Sometimes, a liquid like water can be evacuatedd“ water cancerous”dtypical in gastric cancer. Rarely it is possible that the vomiting contains pus from an open abscess in or around the stomach. 4.2.5.3 Questionnaire 1. When did the vomiting start? If it appears in the morning, it is typical of alcoholism and pregnancy. 2. How many times do you vomit per day? Once, occasionally, or repeatedly can suggest pyloric stenosis. 3. How often does the vomiting occur? Rarely or very frequently could be hyperemesis in pregnancy or pyloric stenosis. 4. Is it preceded by nausea? Usually vomiting is preceded by nausea in almost all the diseases, but sometimes the nausea is missingdtypical in central vomitingdsuggesting intracranial hypertension. 5. Is it with a sudden onset and “in jet”? The sudden onset in jet is typical of central vomiting. 6. At what hour during the day does it occur? In the morning before eating is typical of pregnancy, chronic alcoholism, and pyloric stenosis. 7. Was it just one episode or repeated? Repeated episodes of vomiting are typical of pyloric stenosis. 8. How do you estimate the quantity of vomiting? Small quantity occurs in neurosis (hysteria) and increased quantity occurs in pyloric stenosis. 9. Do you feel a particular or bad smell? Smell of “rotten eggs” suggests stomach cancer. 10. Do you feel a taste? Bitter taste suggests gallbladder disease. Sour taste suggests stomach disease such as ulcer or gastritis. 11. What do you observe regarding the content of the vomit? Usually the contents of vomit include ingested food and bile because of duodenalegastric reflux. Rarely, the vomiting can contain stool, late in occlusion of the bowel; a liquid like water, “cancerous water” appears in gastric cancer; extremely rarely it can contain pus if there exists an abscess around the stomach and fistulas and open inside the stomach. Other special situations are when the patient sees fresh blood in the vomit, which is suggestive of gastric or duodenal ulcer, bleeding gastritis, broken esophageal varices, or MalloryeWeiss syndrome (when there appears a small quantity of fresh blood in the vomit after an effort of repeated vomiting). 12. Do you see bile in the vomit? This is common; all vomits contain bile, but in pyloric stenosis it is missingdthis is a special condition. 13. Do you see food taken in (eaten) many days ago and undigested? This is typical of pyloric stenosis. 14. Do you see a specific color? Green color suggests bile in the vomit. Yellow color suggests gastric juice and originates from the stomach. Light green vomiting, appears typically in peritonitis. Like water suggests gastric cancer. Fresh blood suggests upper bleeding. Black blood like “coffee grounds” suggests old upper bleeding. 15. Do you see fresh blood? In what quantity? No. This is OK. Yes. In small quantity or in increased quantities suggests upper bleeding in small or increased quantity. 16. Do you vomit only fresh blood?
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No. This is OK. Yes. This is hematemesis. This suggests upper bleeding and we must find the cause. Usually the cause is gastric ulcer, duodenal ulcer, bleeding gastritis, gastric cancer, or breaking of esophageal varices in liver cirrhosis. This is a severe emergency and the patient must be hospitalized.
Hematemesis in a patient with gastric ulcer
17. Do you vomit black blood like coffee grounds? No. This is OK Yes. If you vomit black blood like coffee groundsdthis suggests upper bleeding, but the color is black like coffee grounds because the blood stayed for a period of time in the stomach and digestive enzymes auctioned in the stomach and the blood was not evacuated immediately as fresh. 18. Do you observe black stools at the same time? No. The color of the stool was normaldbrown. This is OK. Yes. This suggests the presence of digested blooddblack stooldmelena as shown in the image below, typical of upper bleeding.
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Melenadblack stoolsddigested blood suggests upper bleeding in a patient with gastric ulcer
19. Do you feel dizzy? No. This is OK. Yes. This can appear in upper bleeding because the blood pressure is decreased (arterial hypotension) and in the context of anemia as well. 20. Do you experience faintness? No. It is OK. Yes. This exists in upper bleeding. Arterial hypotension and anemia can develop faintness. 21. What did you eat before the vomiting starts? I ate eggs and fatty meat and then the vomiting started These foods are typical for biliary colic. I ate a lot of fat and I drank alcohol with my friends because it was Christmas and we celebrated this event, but after that started repeated vomiting and epigastric pain. This is typical of acute pancreatitis. 22. What drugs did you take before the start of the hematemesis and melena? No drugs. I drank alcohol. Drugs such as aspirin, NSAIDs, and prednisone are very well known for their side effects such as upper bleeding externalized by melena or hematemesis or both at the same time in a patient with ulcer. 23. Do you have vomiting and diarrhea at the same time? No. This is OK. Yes. This is typical of acute gastroenteritis or food poisoning. 24. Do you experience nausea, vomiting, chills, and fever? No. This is OK. Yes. This possibly suggests an acute cholecystitis. 25. Do you experience headache and vomiting? No. This is OK. Yes. This can suggest stroke or tumor of the brain.
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26. Do you have headache, vomiting, chills, and fever? No. This is OK. Yes. This suggests the possibility of acute meningitis. 27. Did you used drugs such as cocaine and then experience vomiting? No. this is OK. Yes. You may have cocaine drug intoxication.
4.2.6 Hematemesis The definition of hematemesis is vomiting with fresh blood. The color of the blood depends on how long the blood stays inside the stomach. In massive bleeding the stomach cannot tolerate the blood inside, and for this reason the blood will be immediately expelled from the stomach and the color will be like that of fresh blood as shown in the following images. In these images we see a patient known with gastric ulcer, who came to the emergency department because he vomited a massive quantity of fresh blood (hematemesis) after drinking alcohol. The image shows the patient in bed with a nasalegastric tube (NG tube) for aspiration with fresh blood from the stomach:
The patient with the NG tube for aspiration had fresh blood coming from the stomach because he had chronic gastric ulcer and hematemesis after drinking alcohol. In the next images we can see the color of the blood in the pouch after was evacuated by NG tube from the stomach:
Hematemesisdfresh blood collected inside the pouch from nasalegastric tube aspiration
The most important differential diagnosis of hematemesis is hemoptysis, when the patient expectorates blood after coughing, and in this case the source of bleeding is the lung. When the patient has hematemesis, the vomit contains blood and the source of bleeding is the stomach. Sometimes a massive epistaxis or bleeding from gums can be swallowed and after that eliminated during vomiting, but only a very careful history of the patient can help to differentiate this situation from a real hematemesis; there can be confusion.
4.2.7 Melenadblack stoolsdupper bleeding If the bleeding is in small quantities inside the stomach, there exists enough time for HCl to transform the hemoglobin into hematin and color of the blood becomes black like coffee grounds. Some of the blood from the stomach passes to the duodenum, followed by digestion, and will be eliminated through pitch-black stooldmelena. In the image below, we can see the typical appearance of melenadblack stool suggests digested blood.
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Melenadblack stoolsdupper bleeding
4.2.8 Hematemesis and melena represent the main signs of upper bleeding Sometimes a patient can have hematemesis or melena. Otherwise a patient can have both together (hematemesis and melena) depending on the severity of bleeding. In the first instance it is important to recognize the signs and after that to find the etiology of the risk factors. The most common causes of upper bleeding are the following diseases: gastric ulcer, duodenal ulcer, bleeding gastritis, gastric cancer, polyps of the stomach, broken esophageal varices, and others. The most common drugs used in medical practice that can develop side effects such as upper bleeding externalized by hematemesis or melena are aspirin, NSAIDs, and prednisone. Another important idea is that a few categories of drugs, such as bismuth salts, iron therapy, and medicinal coal, may turn the stool a black color during therapy with these drugs. The stool macroscopically looks like melena, but in reality this is false melena because the stool does not contain blood inside. After the period of therapy with these drugs stops, the color of the stool becomes normaldbrown. Other examples of false melena come from foods. If a person eats cranberries, black blueberries, blackberries, or blood sausage, the stool may appear black because of these foods; but the stool does not contain blood.
4.3 The Objective General Examination 4.3.1 “Squat” Attitude If a patient has epigastric pain in the context of gastric ulcer, in penetration crises, or in perforation of an ulcer he or she may adopt spontaneously a “squat” attitude, pressing the epigastric region with fists.
4.3.2 Muscle Contracture If there appears to be a perforated ulcer in the peritoneal cavity because it peritoneal irritation has developed and the abdominal muscle develops reflex contracture, we cannot palpate the abdomen. However, as much as we try to push with the hands on the abdomen, it is hard, and we cannot push inside because the consistency has changed from soft to hard. This is a “wooden abdomen” because of the contracture of the muscle and a very important sign at the objective examination because it is a surgical emergency and the patient must be sent immediately to the surgery department for laparotomy.
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4.3.3 Zygomatic Face The zygomatic face appears typically in ulcer (gastric or duodenal ulcer) and shows a prominence of the zygomatic arcade; and because of a diminished Bichat bulla, the nasalelabial grooves are obvious. This type of face is typical in ulcer and also in pyloric stenosis because the patient has had repeated vomiting and suffered heavy weight loss because of no food assimilation; consequently the Bichat bulla decreases, because this contains fat, and in consequence the zygomatic arcade becomes preeminent. We can recognize this type of face very easily because it looks as shown in the following images.
Zygomatic face in a patient with gastric ulcer; prominence of the zygomatic arcade
Zygomatic face in a patient with pyloric stenosis
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4.3.4 Paleness Paleness appears typically after bleeding because the patient loses blood and has anemic syndrome. The higher the amount of blood lost, the more intense is the pallor of the skin and the mucosa. If a patient has had hematemesis in increased quantities and/or melena as a result of upper bleeding, the color of the skin will be pale as shown in the following image. 4.3.4.1 Paleness of the face after upper bleeding externalized by hematemesis and melena
In the images below we can observe also the paleness of the palm and palmar creases because the level of hemoglobin has decreased to Hb ¼ 7 g/dL. The photo with comparative examination between the palm of the patient and the normal palm of the examiner is very suggestive because palms are a natural hemoglobin meter. 4.3.4.2 Paleness of the palm and the palmar creases
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4.3.4.3 The palm of the examiner compared with the paleness of the palm of the patientdthe palm, being a natural hemoglobin meter, suggests anemia
4.3.5 Emaciation Emaciation represents the situation in which a patient loses a lot of weight. In the stomach diseases, this is common in gastric cancer and pyloric stenosis.
Emaciation in a patient with gastric cancer
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4.3.6 Sign of virchoweTroisier VirchoweTroisier’s sign is a very important sign typical in gastric carcinoma. In this situation, because there is metastasis in the lymph nodes system in one moment, it is possible for an enlarged lymph node located in the right supraclavicular area to appear. This is a typical sign of VirchoweTroisier, which suggests the diagnosis of adenocarcinoma of the stomach, as shown in the image below.
Enlarged lymph node in right supraclavicular area marked with a red star suggests indirectly the diagnosis of cancer of the stomach
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It is important to recognize this sign in medical practice because it is specific; but the problem is that at the moment when it is present, the diagnosis is late because the patient already has gastric cancer but in the phase of metastasis. So only palliative protocol methods such as chemotherapy can be used, and patient is in the late stage of disease. We must make efforts in our medical practice to diagnose stomach cancer in early stages to be able to save the patient’s life.
4.4 The Objective Examination of the Stomach 4.4.1 The Inspection 4.4.1.1 Bulging of the Epigastric Region Bulging of the epigastric region is very easy to recognize at the first look, if we are careful; and it appears as a big tumor of the stomach and in pyloric stenosis because the stomach cannot evacuate normally to become empty 6e8 h after food intake. 4.4.1.2 Retractable Epigastric Region The retractability of the epigastric region occurs after perforation of the ulcer and appears also in the emaciated patient who loses a lot of weight as shown in the image below:
Throbbing bulge (swell)
A throbbing bulge can appear when a tumor comes in contact with the abdominal aorta, and for this reason the abdominal pulsation of the aorta is transmitted.
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4.4.1.3 Sign of Kussmaul
Kussmaul’s sign
4.4.1.4 Intermittent Epigastric Tension of Bouveret
The epigastric tension of Bouveret
Both Kussmaul’s sign and the tension of Bouveret appear typically in pyloric stenosis. If we are careful, at the simple inspection of the abdomen, we can recognize these signs and the physician can suspect clinically the diagnosis of pyloric stenosis. Because there exists a stenosis of the pyloric area, the stomach tries to push the food inside to pass the pyloric area, but it is very difficult and there exists an incomplete evacuation of the stomach. This effort of the stomach appears evidently like peristaltic movements on the abdomen in the epigastric area from right to left and up to down, indicated by arrows in the photo above. This visualization, on inspection of these peristaltic movements, represents Kussmaul’s sign. Sometimes, intermittently, the entire stomach contracts because it tries to push the food inside it with all force to pass the pyloric stenosis area. In this situation a bulging region appears in the epigastric area, and this is the intermittent epigastric tension of Bouveret shown in the image above.
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In the late stage antiperistaltic movements appear, indicated by a red arrow on the abdomen, when the stomach can compensate the situation and becomes a decompensate phase of pyloric stenosis.
4.4.2 The Palpation 4.4.2.1 The Superficial Palpation The superficial palpation can put in evidence sensitivity in the epigastric area. This is present in stomach diseases such as gastritis, ulcer, and stomach cancer, but also in diseases of pancreas such as acute pancreatitis or in posterioreinferior myocardial infarction. “Muscle defense” is a sensation when the doctor feels that he or she cannot easily push the abdomen in the epigastric area inside with fingers and hands because there is a resistance. This appears typically in complication of ulcerd crises of penetration of ulcer or real ulcer perforationdand is an important sign. 4.4.2.1.1 The Superficial Bimanual Palpation
We can detect sensitivity or muscle defense.
4.4.2.2 The Deep Palpation
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The deep palpation can be monomanual, one hand is used as shown in the image above, or bimanual, when we use two hands. During deep palpation the physician can induce pain and can feel tumor formation in the epigastric area of the stomachdtumor of the stomach or tumor of the pancreas or tumor of the transversal colon could be also detected after deep palpation in the epigastric area. The gastric clapotage sign is a very important and specific sign for pyloric stenosis. The sign is shown in the following image. The physician catches a skin fold with the hand exactly in the epigastric area and after that performs a few jiggling movements. If a hydroaeric sound is heard with low tonality, which is the result of a combination of food and secretions in the gases bulla of the stomach, after these movements, this is a sign of incomplete evacuation of the stomach if it is positive in the morning or before eating when the stomach should be empty. 4.4.2.3 The Gastric Clapotage Sign
The gastric clapotage sign
4.4.3 Percussion The percussion of the stomach is very difficult to perform because the stomach is a deep organ inside the abdomen and the limit of the percussion method is only 7 cm deep, not more than that. For this reason we cannot say that the method of percussion presented is really important for the stomach. 4.4.3.1 The Percussion of the Stomach
The percussion of the stomach
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4.4.4 Auscultation Swallowing noises (sounds) can be heard with the stethoscope placed in the epigastric area when the patient swallows water, because they appear when there exists an obstacle in the epigastric junction.
4.5 The Complementary Investigations of the Stomach 4.5.1 The Radiological ExaminationdBarium Swallow Test; Morphological Examination of the Stomach Barium SwallowdNiche ImagedRecess in a Wall 4.5.1.1 Nichedrecess in a wallddirect sign of ulcer
The image is of a barium swallow in a patient with severe epigastric pain like a burn immediately after eating; in a smoker and alcoholic person, the image is typical of the presence of a niche on the small curvature of the stomachda direct sign of gastric ulcer.
A niche on the small curvature of the stomach
4.5.1.2 Gap Image e Significant a Solid Mass inside of the stomach
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Gap imagedsignifies a solid mass inside the stomachdlooks black in color and suggests the presence of a tumor inside the stomach
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4.5.1.3 The deformed duodenal “bulb in clover” appears in the chronic duodenal ulcer
4.5 The Complementary Investigations of the Stomach
4.5.1.4 Rigidity Segmentation
Rigidity segmentation appears in infiltrative gastric cancer
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4.5.1.5 Stomach dilation - like sink-shaped snowflakes Stomach is in the form of a sink - and the barium solution inside of the stomach is like snowflakes. Pyloric Stenosis
Stomach dilatation like sink-shaped snowflakes
4.5.2 The Upper EndoscopydGastroscopy The upper endoscopy represents the gold standard investigation of the stomach in the new era. It is a very useful method because we can see exactly how the mucosa of the stomach looks, and it also gives the opportunity to preserve a biopsy from the mucosa or lesions; and the histopathology examination from the biopsy can establish the nature, benign or malign. The most important and common lesions discovered after gastroscopy are: • • • • •
gastric ulcer duodenal ulcer gastric cancer gastric polyposis pyloric stenosis
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• astroesophageal reflux • upper bleeding If a gastric ulcer is seen, there must be a preserved biopsy to know if the lesion is a malignant ulcer. Another advantage of endoscopy is therapeutic, because upper bleeding can be stopped with this procedure or one can ligature broken esophageal varices and stop bleeding in patients with liver cirrhosis and esophageal varices. Sometimes the patient refuses to undergo upper endoscopy because it is an invasive method, and sometimes it is difficult to tolerate; and of course there exists also a few contraindications in the procedure. Lately video-capture and modern procedures have appeared for investigating the upper and also the lower digestive tracts, which are very well performed, are easily tolerated by the patient, and in time may substitute for the endoscopy procedure. The future remains open for research to find other important and easy methods to investigate the stomach and to change the actual situation, but at present these are the ones used in medical practice. 4.5.2.1 Upper Bleeding Melenadblack stoolsdupper bleeding
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4.5 The Complementary Investigations of the Stomach
Upper BleedingdMelena
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4.5.2.1.3 MelenadBlack Stool
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4.5 The Complementary Investigations of the Stomach
Rectal Touch
Black Stool
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4.5.2.1.4 Melena on the Gloved Finger
4.5.2.1.5 Therapydnasogastric tube aspiration in a patient with hematemesis
4.5 The Complementary Investigations of the Stomach
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4.5 The Complementary Investigations of the Stomach
4.5.2.1.6 Blood in the Pouch After NasoGastric Aspiration
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4.5.2.1.7 Blood Transfusion
Blood Oþ for transfusion
4.5 The Complementary Investigations of the Stomach
Blood Transfusion
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Blood transfusion with blood ISO groupdISO Rh
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4.6 Clinical Case of the Stomach 4.6.1 Clinical Case Presented is the clinical case of a 48-year-old man, who was found in a bedroom with fresh blood around him. He was very pale; his blood pressure value was 70/40 mm Hg. He was vomiting fresh blooddhematemesisdand immediately was put on an NG tube, and we can see in the image below that fresh blood came out of the stomach.
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After the patient was put in bed, he also presented with black stool, melena, as we can see in the images below.
4.6 Clinical Case of the Stomach
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Rectal Touch
The patient had upper bleeding exteriorized with hematemesis and melena and needed a blood transfusion of ISO group, ISO Rh, as we can see in the following images. Before transfusion the Hb level was 6 g/dL.
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Regarding the cause of upper bleeding, the patient reported that he takes aspirin and drinks alcohol, as well, and he had a gastric ulcer. Gastroscopy confirmed the diagnosis of gastric ulcer and upper bleeding due to the gastric ulcer. The patient also received hemostatic drugs and proton pump inhibitors for a week, with good evolution. In conclusion, for the patient with gastric ulcer, the consumption of aspirin and alcohol is contraindicated because it can develop a massive upper bleeding, exteriorized by hematemesis and melena, and can put the patient’s life in danger, who may die of hemorrhagic shock without therapy.
THE SEMIOLOGY OF THE STOMACH AND DUODENUM
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4 The Semiology of the Stomach and Duodenum O U T L I N E 4.1 Questionnaire
4.2 Symptoms 295 4.2.1 Epigastric Pain 296 4.2.2 BelchingdEructation 299 4.2.3 Regurgitation 299 4.2.4 HeartburndPyrosis 299 4.2.5 Vomiting 299 4.2.6 Hematemesis 304 4.2.7 Melenadblack stoolsdupper bleeding 305 4.2.8 Hematemesis and melena represent the main signs of upper bleeding 306 4.3 The Objective General Examination 4.3.1 “Squat” Attitude 4.3.2 Muscle Contracture 4.3.3 Zygomatic Face 4.3.4 Paleness 4.3.5 Emaciation
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4.3.6 Sign of virchoweTroisier
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4.4 The Objective Examination of the Stomach 4.4.1 The Inspection 4.4.2 The Palpation 4.4.3 Percussion 4.4.4 Auscultation
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4.5 The Complementary Investigations of the Stomach 315 4.5.1 The Radiological ExaminationdBarium Swallow Test; Morphological Examination of the Stomach Barium SwallowdNiche ImagedRecess in a Wall 315 4.5.2 The Upper EndoscopydGastroscopy 320 4.6 Clinical Case of the Stomach 4.6.1 Clinical Case
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4.2 Symptoms
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4.1 Questionnaire 1. Where did the pain start? Were you feeling pain in the first instance? I feel pain in the epigastric areadepigastric pain. This is the location. 2. What does the pain feel like? Can you compare it with something? I feel the pain like a burning sensation. This is the characteristic. 3. How long has the pain been going on? I have been feeling the pain for 15 min. This is the duration. 4. Where did you feel the pain radiate, starting from the epigastric area? After the pain started in the epigastric area, I felt the pain in the back. This is the irradiation. I feel the pain only in the epigastric area. This is without irradiation. 5. Under what conditions does the epigastric pain appear? I feel the epigastric pain when my stomach is empty before eating. I feel the epigastric pain after eating. These are the conditions of appearance. The correlation with eating is very important when we characterize epigastric pain, because we can suspect directly the diagnosis of gastric ulcer or duodenal ulcer if we are careful in how we ask the patient, and it depends on what answer we receive. For example, if the epigastric pain appears before eating, this is suggestive of duodenal ulcer; and if the epigastric pain appears after eating, this is very suggestive of gastric ulcer. 6. Under what conditions does the epigastric pain disappear? What ameliorates the epigastric pain? If I eat something, it stops my epigastric pain. This is typical of duodenal ulcer. If I drink a cup of milk and a few biscuits, it stops my epigastric pain. Also, alkaline substances stop my epigastric pain. This is typical of bothd epigastric and duodenal ulcer. These are the conditions of extinction. 7. What other symptoms do you feel at the same time with the epigastric pain? I feel nausea. This is the accompanying symptom. I do not feel anything else, only epigastric pain. This is without symptoms of accompaniment. I feel nausea and dizziness. These are the accompanying symptoms.
4.2 Symptoms The main symptoms of stomach diseases are very important because these attract the attention of the physician to the pathology of the stomach. If we recognize these symptoms in a patient, we must suspect a stomach disease. The most important symptoms are: • • • • • •
Epigastric pain Belching or eructation Regurgitation Heartburn (pyrosis) Vomiting Hematemesis
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4.2.1 Epigastric Pain Epigastric pain is typically located in the epigastric area and very suggestive of stomach disease, but it can also suggest acute pancreatitis or an acute posterioreinferior myocardial infarction (heart attack). 4.2.1.1 Correlation with alimentation The very important characteristic of epigastric pain in stomach disease is that this is in correlation with alimentation. 4.2.1.1.1 Gastric ulcer e Epigatric pain - After Eating Epigastric pain in gastric ulcer appears after alimentation. This can possibly appear immediately after a person eats or after 1e2 h or even later than that, after 3e4 h. The most important idea is that all the time in gastric ulcer, the pain appears after eating. For this reason the patient avoids eating to not start the epigastric pain and suffers weight loss. It is possible to suspect the location of a gastric ulcer in correlation with time and when the pain starts after eating: immediately after alimentation is suggestive of an ulcer around the cardia and after 1e2 h suggests postoperative peptic ulcer and later, at 3e4 h, suggests pyloric ulcer. In the following image we can see the correlation of pain after alimentation. After EatingdI Have Epigastric Pain
In the image above a red lightning bolt indicates the area of the abdomen where the patient with stomach disease feels pain, the epigastric area.
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4.2.1.1.2 Duodenal ulcer e Epigastric pain - Before Eating In duodenal ulcer the epigastric pain appears before eating, when the stomach is empty. In the following image this phenomenon is illustrated. I didn’t eat anything in the morning and at lunch and I feel intense epigastric pain. What is wrong with me?
Epigastric pain before eatingdsuggestive of duodenal ulcer
Also, when epigastric pain appears during the night or after the middle of the night, when the stomach is empty, and it wakes the patient up from sleep, this situation is again typical of duodenal ulcer. The phenomenon is illustrated in the following image. I do not eat anything and I feel sudden epigastric pain in the middle of the night. This is also typical of duodenal ulcer, because in this period the stomach is empty.
4.2.1.1.3 Duodenal ulcer - Epigastric pain during the night
Epigastric pain during the nightdtypical of duodenal ulcer
Usually if the patient eats a few biscuits and drinks a cup of milk, the epigastric pain ameliorates or stops. Because the pain stops after eating in duodenal ulcer, these categories of patients eat frequently to stop the pain; and for this reason these patients gain weight and can become obese, different from the patients with gastric ulcer, who lose weight, because the eating develops pain and they avoid eating. 4.2.1.1.4 Small periodicity Because the patient suffers every day and at every meal with this correlation between epigastric pain and alimentation, this phenomenon is of a small periodicity. If these incidences occur for a period of a few weeks during spring and autumn, this phenomenon is of a large periodicity. 4.2.1.2 Big periodicity Usually, if the ulcer is not complicated, the epigastric pain does not irradiate. When the patient feels irradiation of the pain, this suggests a complication of the ulcer. For example, if the pain irradiates into the back, this is suggestive of a penetration of the ulcer to the pancreas. The first time a patient comes in to the physician with epigastric pain, we must ask the patient these most important questions, and in this way we can differentiate the most important characteristics of the pain.
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4.2.2 BelchingdEructation The definition of belching or eructation is the removal of gas from the stomach through the mouth. If a person eats quickly and swallows airdaerophagiadand then feels the need to eliminate gases through the mouth, eructation occurs. In this situation the eructation does not have any smell. In pyloric stenosis, because the food is not evacuated normally from the stomach and remains there for a long period of time and stagnates, a fermentative process occurs; and because of this, when a patient with pyloric stenosis develops eructation, it will be with a bad smell like “rotten eggs.”
4.2.3 Regurgitation The definition of regurgitation is the returning of food from the stomach into the mouth, occurring typically in hiatal hernia. Gastric regurgitation occurs with a sour taste and acidic sensation.
4.2.4 HeartburndPyrosis Pyrosis is the heartburn sensation and is typical in gastric and duodenal ulcer as well as in the esophageal diseases. The patient feels the epigastric pain sometimes like a burning sensation. This is typical pyrosis and sometimes can substitute for the pain. Alkaline substances can stop this, or ingestion of milk because it is alkaline, and biscuits stop pyrosis. In gastroesophageal ebb the patient feels pyrosis in the retrosternal area and develops reflux esophagitis.
4.2.5 Vomiting The definition of vomiting is the elimination of the contents of the stomach and bowel through the mouth. Usually vomiting is preceded by nausea, but rarely it is possible to be without nausea in central vomitingd“vomiting jet.” There are two major types of vomiting: central and peripheral. 4.2.5.1 Central Vomiting Central vomiting is typically without nausea and in a jet and is specific for all the diseases that develop intracranial hypertension. This situation is specific to hypertensive patients, who can develop hypertensive encephalopathy, cerebral edema, and intracranial hypertension. The most common example is in stroke attackdbleeding stroke attack. The situation must be recognized as early as possible and not be confused with peripheral vomiting such as in digestive diseases, because in this case, without a correct therapy in time, the patient can develop an unexpected deep coma and sudden death. Another important cause of central vomiting is trauma to the head, when the patient loses consciousness for a period of time and develops a hematoma of the brain. Because this develops intracranial hypertension it represents a cause of central vomiting, which appears suddenly, without nausea, and in a jet. A tumor of the brain or other solid masses inside the brain can also develop intracranial hypertension and central vomiting. Of course, in all these situations, a CT scan of the brain must be performed immediately. The main important idea is not to confuse in medical practice central vomiting that has neurological causes with the totally different protocol management therapy for peripheral vomiting with other characteristics that suggest digestive disease. INTRACRANIAL HYPERTENSIONdCENTRAL VOMITING
INTRACRANIAN HYPERTENSION
CENTRAL VOMITTING
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4.2.5.2 Peripheral Vomiting Peripheral vomiting is the most common type of vomiting in medical practice. The patient feels nausea before vomiting, and the causes of this type represent many digestive diseases such as stomach, gallbladder, liver, pancreas, small bowel, enlarged bowel, peritoneal irritation, and annexitis in women. In these conditions vomiting appears as a reflex after causes from the digestive tract or peritoneum that stimulate the vomiting center. There are various examples of diseases that can develop peripheral vomiting in medical practice, such as gastritis, pyloric stenosis, gastric cancer, acute viral hepatitis, food poisoning, acute pancreatitis, occlusion of the small bowel or enlarged bowel, enteritis, gastroenteritis, acute peritonitis, metroanexitis, pregnancy, renal colic, and so on. DIGESTIVE DISEASESdPERIPHERAL VOMITING
DIGESTIVE DISEASES
PERIPHERAL VOMITTING
The semiologic analysis of vomiting follows these important characteristics: 4.2.5.2.1 Frequency FrequencydHow often does vomiting occur? How many times per day? It can occur occasionally, for example, when a person smells a bad odor, or repeatedly, in pyloric stenosis, or very oftendthe patient feels that he or she cannot stop vomiting, in pregnancy, hyperemesis, or severe intoxication with a toxic substance, such as lead or others. 4.2.5.2.2 Timing and rhythm Period: the time of day or night and the relationship with fooddIn what period of day does vomiting occur? If vomiting occurs later than two hours after eating, this suggests pyloric stenosis; in the morning before eating is typical of alcoholic people, chronic ethylic patients, or in pregnancy; in neurosis the patient commonly presents with vomiting during lunch; and vomiting during the night occurs in duodenal ulcer. 4.2.5.2.3 Volume VolumedIn pyloric stenosis, the volume of vomiting is increased because incompletely evacuated food remains inside the stomach for many days; and in hysteria and pregnancy, the volume is small. 4.2.5.2.4 The smell The smelldIt could be like feces in an occlusion of the bowel, rancid in pyloric stenosis, or acidic in hyperacidity. 4.2.5.2.5 Vomiting content Vomit contentdThe contents could include undigested food, which appears typically in pyloric stenosis and also in the morning before eating when the stomach normally must be empty. A quantity of bile is present in almost every vomiting because of the duodenal reflux, but in pyloric stenosis it is absent.
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If the vomiting is green like leeks, this is typical in peritonitis. Sometimes, a liquid like water can be evacuatedd“ water cancerous”dtypical in gastric cancer. Rarely it is possible that the vomiting contains pus from an open abscess in or around the stomach. 4.2.5.3 Questionnaire 1. When did the vomiting start? If it appears in the morning, it is typical of alcoholism and pregnancy. 2. How many times do you vomit per day? Once, occasionally, or repeatedly can suggest pyloric stenosis. 3. How often does the vomiting occur? Rarely or very frequently could be hyperemesis in pregnancy or pyloric stenosis. 4. Is it preceded by nausea? Usually vomiting is preceded by nausea in almost all the diseases, but sometimes the nausea is missingdtypical in central vomitingdsuggesting intracranial hypertension. 5. Is it with a sudden onset and “in jet”? The sudden onset in jet is typical of central vomiting. 6. At what hour during the day does it occur? In the morning before eating is typical of pregnancy, chronic alcoholism, and pyloric stenosis. 7. Was it just one episode or repeated? Repeated episodes of vomiting are typical of pyloric stenosis. 8. How do you estimate the quantity of vomiting? Small quantity occurs in neurosis (hysteria) and increased quantity occurs in pyloric stenosis. 9. Do you feel a particular or bad smell? Smell of “rotten eggs” suggests stomach cancer. 10. Do you feel a taste? Bitter taste suggests gallbladder disease. Sour taste suggests stomach disease such as ulcer or gastritis. 11. What do you observe regarding the content of the vomit? Usually the contents of vomit include ingested food and bile because of duodenalegastric reflux. Rarely, the vomiting can contain stool, late in occlusion of the bowel; a liquid like water, “cancerous water” appears in gastric cancer; extremely rarely it can contain pus if there exists an abscess around the stomach and fistulas and open inside the stomach. Other special situations are when the patient sees fresh blood in the vomit, which is suggestive of gastric or duodenal ulcer, bleeding gastritis, broken esophageal varices, or MalloryeWeiss syndrome (when there appears a small quantity of fresh blood in the vomit after an effort of repeated vomiting). 12. Do you see bile in the vomit? This is common; all vomits contain bile, but in pyloric stenosis it is missingdthis is a special condition. 13. Do you see food taken in (eaten) many days ago and undigested? This is typical of pyloric stenosis. 14. Do you see a specific color? Green color suggests bile in the vomit. Yellow color suggests gastric juice and originates from the stomach. Light green vomiting, appears typically in peritonitis. Like water suggests gastric cancer. Fresh blood suggests upper bleeding. Black blood like “coffee grounds” suggests old upper bleeding. 15. Do you see fresh blood? In what quantity? No. This is OK. Yes. In small quantity or in increased quantities suggests upper bleeding in small or increased quantity. 16. Do you vomit only fresh blood?
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No. This is OK. Yes. This is hematemesis. This suggests upper bleeding and we must find the cause. Usually the cause is gastric ulcer, duodenal ulcer, bleeding gastritis, gastric cancer, or breaking of esophageal varices in liver cirrhosis. This is a severe emergency and the patient must be hospitalized.
Hematemesis in a patient with gastric ulcer
17. Do you vomit black blood like coffee grounds? No. This is OK Yes. If you vomit black blood like coffee groundsdthis suggests upper bleeding, but the color is black like coffee grounds because the blood stayed for a period of time in the stomach and digestive enzymes auctioned in the stomach and the blood was not evacuated immediately as fresh. 18. Do you observe black stools at the same time? No. The color of the stool was normaldbrown. This is OK. Yes. This suggests the presence of digested blooddblack stooldmelena as shown in the image below, typical of upper bleeding.
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Melenadblack stoolsddigested blood suggests upper bleeding in a patient with gastric ulcer
19. Do you feel dizzy? No. This is OK. Yes. This can appear in upper bleeding because the blood pressure is decreased (arterial hypotension) and in the context of anemia as well. 20. Do you experience faintness? No. It is OK. Yes. This exists in upper bleeding. Arterial hypotension and anemia can develop faintness. 21. What did you eat before the vomiting starts? I ate eggs and fatty meat and then the vomiting started These foods are typical for biliary colic. I ate a lot of fat and I drank alcohol with my friends because it was Christmas and we celebrated this event, but after that started repeated vomiting and epigastric pain. This is typical of acute pancreatitis. 22. What drugs did you take before the start of the hematemesis and melena? No drugs. I drank alcohol. Drugs such as aspirin, NSAIDs, and prednisone are very well known for their side effects such as upper bleeding externalized by melena or hematemesis or both at the same time in a patient with ulcer. 23. Do you have vomiting and diarrhea at the same time? No. This is OK. Yes. This is typical of acute gastroenteritis or food poisoning. 24. Do you experience nausea, vomiting, chills, and fever? No. This is OK. Yes. This possibly suggests an acute cholecystitis. 25. Do you experience headache and vomiting? No. This is OK. Yes. This can suggest stroke or tumor of the brain.
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26. Do you have headache, vomiting, chills, and fever? No. This is OK. Yes. This suggests the possibility of acute meningitis. 27. Did you used drugs such as cocaine and then experience vomiting? No. this is OK. Yes. You may have cocaine drug intoxication.
4.2.6 Hematemesis The definition of hematemesis is vomiting with fresh blood. The color of the blood depends on how long the blood stays inside the stomach. In massive bleeding the stomach cannot tolerate the blood inside, and for this reason the blood will be immediately expelled from the stomach and the color will be like that of fresh blood as shown in the following images. In these images we see a patient known with gastric ulcer, who came to the emergency department because he vomited a massive quantity of fresh blood (hematemesis) after drinking alcohol. The image shows the patient in bed with a nasalegastric tube (NG tube) for aspiration with fresh blood from the stomach:
The patient with the NG tube for aspiration had fresh blood coming from the stomach because he had chronic gastric ulcer and hematemesis after drinking alcohol. In the next images we can see the color of the blood in the pouch after was evacuated by NG tube from the stomach:
Hematemesisdfresh blood collected inside the pouch from nasalegastric tube aspiration
The most important differential diagnosis of hematemesis is hemoptysis, when the patient expectorates blood after coughing, and in this case the source of bleeding is the lung. When the patient has hematemesis, the vomit contains blood and the source of bleeding is the stomach. Sometimes a massive epistaxis or bleeding from gums can be swallowed and after that eliminated during vomiting, but only a very careful history of the patient can help to differentiate this situation from a real hematemesis; there can be confusion.
4.2.7 Melenadblack stoolsdupper bleeding If the bleeding is in small quantities inside the stomach, there exists enough time for HCl to transform the hemoglobin into hematin and color of the blood becomes black like coffee grounds. Some of the blood from the stomach passes to the duodenum, followed by digestion, and will be eliminated through pitch-black stooldmelena. In the image below, we can see the typical appearance of melenadblack stool suggests digested blood.
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4. The Semiology of the Stomach and Duodenum
Melenadblack stoolsdupper bleeding
4.2.8 Hematemesis and melena represent the main signs of upper bleeding Sometimes a patient can have hematemesis or melena. Otherwise a patient can have both together (hematemesis and melena) depending on the severity of bleeding. In the first instance it is important to recognize the signs and after that to find the etiology of the risk factors. The most common causes of upper bleeding are the following diseases: gastric ulcer, duodenal ulcer, bleeding gastritis, gastric cancer, polyps of the stomach, broken esophageal varices, and others. The most common drugs used in medical practice that can develop side effects such as upper bleeding externalized by hematemesis or melena are aspirin, NSAIDs, and prednisone. Another important idea is that a few categories of drugs, such as bismuth salts, iron therapy, and medicinal coal, may turn the stool a black color during therapy with these drugs. The stool macroscopically looks like melena, but in reality this is false melena because the stool does not contain blood inside. After the period of therapy with these drugs stops, the color of the stool becomes normaldbrown. Other examples of false melena come from foods. If a person eats cranberries, black blueberries, blackberries, or blood sausage, the stool may appear black because of these foods; but the stool does not contain blood.
4.3 The Objective General Examination 4.3.1 “Squat” Attitude If a patient has epigastric pain in the context of gastric ulcer, in penetration crises, or in perforation of an ulcer he or she may adopt spontaneously a “squat” attitude, pressing the epigastric region with fists.
4.3.2 Muscle Contracture If there appears to be a perforated ulcer in the peritoneal cavity because it peritoneal irritation has developed and the abdominal muscle develops reflex contracture, we cannot palpate the abdomen. However, as much as we try to push with the hands on the abdomen, it is hard, and we cannot push inside because the consistency has changed from soft to hard. This is a “wooden abdomen” because of the contracture of the muscle and a very important sign at the objective examination because it is a surgical emergency and the patient must be sent immediately to the surgery department for laparotomy.
4.3 The Objective General Examination
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4.3.3 Zygomatic Face The zygomatic face appears typically in ulcer (gastric or duodenal ulcer) and shows a prominence of the zygomatic arcade; and because of a diminished Bichat bulla, the nasalelabial grooves are obvious. This type of face is typical in ulcer and also in pyloric stenosis because the patient has had repeated vomiting and suffered heavy weight loss because of no food assimilation; consequently the Bichat bulla decreases, because this contains fat, and in consequence the zygomatic arcade becomes preeminent. We can recognize this type of face very easily because it looks as shown in the following images.
Zygomatic face in a patient with gastric ulcer; prominence of the zygomatic arcade
Zygomatic face in a patient with pyloric stenosis
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4.3.4 Paleness Paleness appears typically after bleeding because the patient loses blood and has anemic syndrome. The higher the amount of blood lost, the more intense is the pallor of the skin and the mucosa. If a patient has had hematemesis in increased quantities and/or melena as a result of upper bleeding, the color of the skin will be pale as shown in the following image. 4.3.4.1 Paleness of the face after upper bleeding externalized by hematemesis and melena
In the images below we can observe also the paleness of the palm and palmar creases because the level of hemoglobin has decreased to Hb ¼ 7 g/dL. The photo with comparative examination between the palm of the patient and the normal palm of the examiner is very suggestive because palms are a natural hemoglobin meter. 4.3.4.2 Paleness of the palm and the palmar creases
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4.3.4.3 The palm of the examiner compared with the paleness of the palm of the patientdthe palm, being a natural hemoglobin meter, suggests anemia
4.3.5 Emaciation Emaciation represents the situation in which a patient loses a lot of weight. In the stomach diseases, this is common in gastric cancer and pyloric stenosis.
Emaciation in a patient with gastric cancer
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4.3.6 Sign of virchoweTroisier VirchoweTroisier’s sign is a very important sign typical in gastric carcinoma. In this situation, because there is metastasis in the lymph nodes system in one moment, it is possible for an enlarged lymph node located in the right supraclavicular area to appear. This is a typical sign of VirchoweTroisier, which suggests the diagnosis of adenocarcinoma of the stomach, as shown in the image below.
Enlarged lymph node in right supraclavicular area marked with a red star suggests indirectly the diagnosis of cancer of the stomach
4.4 The Objective Examination of the Stomach
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It is important to recognize this sign in medical practice because it is specific; but the problem is that at the moment when it is present, the diagnosis is late because the patient already has gastric cancer but in the phase of metastasis. So only palliative protocol methods such as chemotherapy can be used, and patient is in the late stage of disease. We must make efforts in our medical practice to diagnose stomach cancer in early stages to be able to save the patient’s life.
4.4 The Objective Examination of the Stomach 4.4.1 The Inspection 4.4.1.1 Bulging of the Epigastric Region Bulging of the epigastric region is very easy to recognize at the first look, if we are careful; and it appears as a big tumor of the stomach and in pyloric stenosis because the stomach cannot evacuate normally to become empty 6e8 h after food intake. 4.4.1.2 Retractable Epigastric Region The retractability of the epigastric region occurs after perforation of the ulcer and appears also in the emaciated patient who loses a lot of weight as shown in the image below:
Throbbing bulge (swell)
A throbbing bulge can appear when a tumor comes in contact with the abdominal aorta, and for this reason the abdominal pulsation of the aorta is transmitted.
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4.4.1.3 Sign of Kussmaul
Kussmaul’s sign
4.4.1.4 Intermittent Epigastric Tension of Bouveret
The epigastric tension of Bouveret
Both Kussmaul’s sign and the tension of Bouveret appear typically in pyloric stenosis. If we are careful, at the simple inspection of the abdomen, we can recognize these signs and the physician can suspect clinically the diagnosis of pyloric stenosis. Because there exists a stenosis of the pyloric area, the stomach tries to push the food inside to pass the pyloric area, but it is very difficult and there exists an incomplete evacuation of the stomach. This effort of the stomach appears evidently like peristaltic movements on the abdomen in the epigastric area from right to left and up to down, indicated by arrows in the photo above. This visualization, on inspection of these peristaltic movements, represents Kussmaul’s sign. Sometimes, intermittently, the entire stomach contracts because it tries to push the food inside it with all force to pass the pyloric stenosis area. In this situation a bulging region appears in the epigastric area, and this is the intermittent epigastric tension of Bouveret shown in the image above.
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In the late stage antiperistaltic movements appear, indicated by a red arrow on the abdomen, when the stomach can compensate the situation and becomes a decompensate phase of pyloric stenosis.
4.4.2 The Palpation 4.4.2.1 The Superficial Palpation The superficial palpation can put in evidence sensitivity in the epigastric area. This is present in stomach diseases such as gastritis, ulcer, and stomach cancer, but also in diseases of pancreas such as acute pancreatitis or in posterioreinferior myocardial infarction. “Muscle defense” is a sensation when the doctor feels that he or she cannot easily push the abdomen in the epigastric area inside with fingers and hands because there is a resistance. This appears typically in complication of ulcerd crises of penetration of ulcer or real ulcer perforationdand is an important sign. 4.4.2.1.1 The Superficial Bimanual Palpation
We can detect sensitivity or muscle defense.
4.4.2.2 The Deep Palpation
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The deep palpation can be monomanual, one hand is used as shown in the image above, or bimanual, when we use two hands. During deep palpation the physician can induce pain and can feel tumor formation in the epigastric area of the stomachdtumor of the stomach or tumor of the pancreas or tumor of the transversal colon could be also detected after deep palpation in the epigastric area. The gastric clapotage sign is a very important and specific sign for pyloric stenosis. The sign is shown in the following image. The physician catches a skin fold with the hand exactly in the epigastric area and after that performs a few jiggling movements. If a hydroaeric sound is heard with low tonality, which is the result of a combination of food and secretions in the gases bulla of the stomach, after these movements, this is a sign of incomplete evacuation of the stomach if it is positive in the morning or before eating when the stomach should be empty. 4.4.2.3 The Gastric Clapotage Sign
The gastric clapotage sign
4.4.3 Percussion The percussion of the stomach is very difficult to perform because the stomach is a deep organ inside the abdomen and the limit of the percussion method is only 7 cm deep, not more than that. For this reason we cannot say that the method of percussion presented is really important for the stomach. 4.4.3.1 The Percussion of the Stomach
The percussion of the stomach
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4.4.4 Auscultation Swallowing noises (sounds) can be heard with the stethoscope placed in the epigastric area when the patient swallows water, because they appear when there exists an obstacle in the epigastric junction.
4.5 The Complementary Investigations of the Stomach 4.5.1 The Radiological ExaminationdBarium Swallow Test; Morphological Examination of the Stomach Barium SwallowdNiche ImagedRecess in a Wall 4.5.1.1 Nichedrecess in a wallddirect sign of ulcer
The image is of a barium swallow in a patient with severe epigastric pain like a burn immediately after eating; in a smoker and alcoholic person, the image is typical of the presence of a niche on the small curvature of the stomachda direct sign of gastric ulcer.
A niche on the small curvature of the stomach
4.5.1.2 Gap Image e Significant a Solid Mass inside of the stomach
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Gap imagedsignifies a solid mass inside the stomachdlooks black in color and suggests the presence of a tumor inside the stomach
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4.5.1.3 The deformed duodenal “bulb in clover” appears in the chronic duodenal ulcer
4.5 The Complementary Investigations of the Stomach
4.5.1.4 Rigidity Segmentation
Rigidity segmentation appears in infiltrative gastric cancer
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4.5.1.5 Stomach dilation - like sink-shaped snowflakes Stomach is in the form of a sink - and the barium solution inside of the stomach is like snowflakes. Pyloric Stenosis
Stomach dilatation like sink-shaped snowflakes
4.5.2 The Upper EndoscopydGastroscopy The upper endoscopy represents the gold standard investigation of the stomach in the new era. It is a very useful method because we can see exactly how the mucosa of the stomach looks, and it also gives the opportunity to preserve a biopsy from the mucosa or lesions; and the histopathology examination from the biopsy can establish the nature, benign or malign. The most important and common lesions discovered after gastroscopy are: • • • • •
gastric ulcer duodenal ulcer gastric cancer gastric polyposis pyloric stenosis
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• astroesophageal reflux • upper bleeding If a gastric ulcer is seen, there must be a preserved biopsy to know if the lesion is a malignant ulcer. Another advantage of endoscopy is therapeutic, because upper bleeding can be stopped with this procedure or one can ligature broken esophageal varices and stop bleeding in patients with liver cirrhosis and esophageal varices. Sometimes the patient refuses to undergo upper endoscopy because it is an invasive method, and sometimes it is difficult to tolerate; and of course there exists also a few contraindications in the procedure. Lately video-capture and modern procedures have appeared for investigating the upper and also the lower digestive tracts, which are very well performed, are easily tolerated by the patient, and in time may substitute for the endoscopy procedure. The future remains open for research to find other important and easy methods to investigate the stomach and to change the actual situation, but at present these are the ones used in medical practice. 4.5.2.1 Upper Bleeding Melenadblack stoolsdupper bleeding
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4.5 The Complementary Investigations of the Stomach
Upper BleedingdMelena
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4.5.2.1.3 MelenadBlack Stool
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Rectal Touch
Black Stool
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4.5.2.1.4 Melena on the Gloved Finger
4.5.2.1.5 Therapydnasogastric tube aspiration in a patient with hematemesis
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4.5 The Complementary Investigations of the Stomach
4.5.2.1.6 Blood in the Pouch After NasoGastric Aspiration
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4.5.2.1.7 Blood Transfusion
Blood Oþ for transfusion
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Blood Transfusion
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Blood transfusion with blood ISO groupdISO Rh
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4.6 Clinical Case of the Stomach 4.6.1 Clinical Case Presented is the clinical case of a 48-year-old man, who was found in a bedroom with fresh blood around him. He was very pale; his blood pressure value was 70/40 mm Hg. He was vomiting fresh blooddhematemesisdand immediately was put on an NG tube, and we can see in the image below that fresh blood came out of the stomach.
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After the patient was put in bed, he also presented with black stool, melena, as we can see in the images below.
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Rectal Touch
The patient had upper bleeding exteriorized with hematemesis and melena and needed a blood transfusion of ISO group, ISO Rh, as we can see in the following images. Before transfusion the Hb level was 6 g/dL.
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Regarding the cause of upper bleeding, the patient reported that he takes aspirin and drinks alcohol, as well, and he had a gastric ulcer. Gastroscopy confirmed the diagnosis of gastric ulcer and upper bleeding due to the gastric ulcer. The patient also received hemostatic drugs and proton pump inhibitors for a week, with good evolution. In conclusion, for the patient with gastric ulcer, the consumption of aspirin and alcohol is contraindicated because it can develop a massive upper bleeding, exteriorized by hematemesis and melena, and can put the patient’s life in danger, who may die of hemorrhagic shock without therapy.