General examination principles and symptom classification
Initial manifestations of gastrointestinal tract pathology are rarely unique. Typical patient complaints, such as epigastric pain, appetite changes, and dyspeptic phenomena (belching, nausea, episodes of vomiting), are nonspecific in nature. They can occur with equal frequency in both gastric lesions and diseases of entirely different organs.
This is precisely why the examination algorithm must be strict and consistent:
- Detailing complaints. A thorough history taking to identify hidden patterns.
- Physical examination. Includes a general inspection of the patient and mandatory abdominal palpation.
- Instrumental methods. These include radiography and EGD (esophagogastroduodenoscopy). These studies are of decisive, final importance for establishing an accurate diagnosis.
All the variety of clinical manifestations with which a patient comes to the doctor can be divided into four main groups:
- Pain syndrome (the main marker of inflammation or mucosal defect).
- Dyspeptic phenomena (disorders of the normal digestive process).
- Gastrointestinal bleeding (a formidable complication).
- Weight loss (requires ruling out severe organic pathology).
Characteristics of pain syndrome
Pain is the most common reason for seeking medical attention. In gastric diseases, it is localized predominantly in the epigastric region. In terms of character, pain sensations can be either constant or paroxysmal (cramping).
The most important characteristic for making a diagnosis is the rhythm of pain—its clear connection with food intake and appearance after a certain time interval. Topical diagnostics is largely based on this sign.
| Type of pain | Localization of the process | Time of onset | Relief features |
|---|---|---|---|
| Early pain | Stomach | 30–60 minutes after eating | Decreases and completely disappears as the food bolus leaves the stomach cavity (in 1–1.5 hours). |
| Late pain | Duodenum (duodenum) | 1.5–3 hours after eating | - |
| Hunger/night pain | Duodenum | On an empty stomach or at night | Subside or completely stop immediately after eating. |
Discomfort and dyspeptic disorders
In addition to severe pain, patients often describe their sensations as discomfort complaints. These include:
- Sensation of heaviness and pressure in the epigastrium. As a rule, this symptom is directly related to stomach overfilling and impaired motor-evacuation function.
- Meteorism (abdominal bloating). Occurs due to increased gas formation. It is important to note that this symptom has a predominantly intestinal genesis, despite the fact that the root cause may lie in impaired gastric digestion.
Assessment of weight loss
Weight loss is a very frequent and clinically significant symptom in gastric and duodenum pathology. The doctor should not limit themselves to simply stating the fact of weight loss; a deep detailing of the complaint is required.
The algorithm for taking a history regarding weight loss includes assessing 6 parameters:
- Weight dynamics: the specific period of time over which the patient lost weight.
- Appetite status: its decrease, pathological increase, or maintenance at the same level.
- Eating behavior: the composition of the daily diet (breakfast, lunch, dinner) and, importantly, the preservation of the sense of pleasure from eating.
- Concomitant dyspepsia: whether weight loss is accompanied by nausea, belching, vomiting, or pain, which may force the patient to consciously refuse food.
- Stool characteristics: any changes in the color and consistency of stool.
- Systemic manifestations: the presence of fever (periodic or constant increase in body temperature).
The main goal of such a detailed interview is to determine the exact localization of the pathological process, find out its duration, and understand the very essence of the disease for a competent differential diagnosis.
Briefly: answers to topical questions
What physical examination methods are used to examine the stomach?
Methods of physical examination of the stomach include general inspection and abdominal palpation.
- General inspection—aimed at detecting weight loss (up to cachexia), pallor of the skin, and a coated tongue.
- Superficial palpation—reveals tenderness in the epigastrium and determines muscle tension (defense).
- Deep sliding palpation—allows palpating the greater curvature (determined as a ridge), the pyloric part (felt as a cord of varying density), and, in rare cases, tumor formations when they are of significant size.
How is Obraztsov-Strazhesko deep methodical sliding palpation of the stomach performed?
Obraztsov-Strazhesko deep methodical sliding palpation of the abdomen is performed on a hard couch without a pillow, with the patient's legs bent to relax the abdominal wall. Breathing should be calm, even, and shallow. The technique includes:
- Placing the palms of both hands (with slightly bent fingers) on the abdominal wall.
- Slowly sinking the fingers deep into the abdomen.
- Sliding movements perpendicular to the axis of the organ being examined.
The purpose of this method is to determine the position, size, shape, mobility of organs and tumors.
What specific changes in stool color and consistency are characteristic of gastrointestinal bleeding?
Gastrointestinal bleeding is characterized by the appearance of melena or gross blood in the stool.
- Melena (Melena)—black, tarry, sticky stool. It is a reliable sign of bleeding from the upper GI tract (it represents blood oxidized by hydrochloric acid).
- Hematochezia is bright red blood in the stool, indicating hemorrhoidal bleeding.
- Unchanged (native) blood appears as red streaks on the surface of the feces, which is characteristic of pathology in the terminal intestine (e.g., anal fissure).
What are the radiological signs of a gastric ulcer?
Radiological signs of a gastric ulcer are divided into direct and indirect.
- The "niche" sign is a direct sign representing a persistent protrusion of the gastric shadow beyond the contour or an accumulation of contrast on the mucosal relief.
- The "pointing finger" sign is a local circular spasm of muscle fibers on the wall opposite to the ulcer defect.
- Convergence of folds is the convergence of mucosal folds toward the "niche".
- Hampton's line (Hampton line) is a thin radiolucent line crossing the ulcer orifice (a reliable sign of a benign defect).
What are the endoscopic criteria for assessing the state of the gastric mucosa during EGD?
During EGD, the following changes in the gastric mucosa are assessed:
- Ulcer defects are visualized with specification of their localization and size.
- Erosions are superficial ulcerations; single or incomplete erosions are more often diagnosed endoscopically.
- Hyperemia — diffuse mucosal hyperemia is detected in acute catarrhal gastritis.
- Signs of antral gastritis with lymphofollicular hyperplasia.
Additionally, EGD allows for a biopsy to achieve morphological verification of the diagnosis and differential diagnosis of benign and malignant ulcers.
"The stomach hurts early, the bowel hurts late." Early pain (30–60 minutes after eating) indicates gastric pathology, while late pain (1.5–3 hours later) and hunger pain indicate duodenal involvement.
Class and exam questions
Why is it impossible to diagnose gastric diseases based on complaints alone?
Typical complaints (epigastric pain, nausea, vomiting) are extremely nonspecific. They occur in many other conditions, which is why instrumental methods — EGD and radiography — are always of decisive importance for the diagnosis.
How to distinguish pain in gastric pathology from duodenal lesions?
The key criterion is rhythmicity. With stomach problems, pain appears early (30–60 minutes after eating) and subsides as the stomach empties. With duodenal pathology, pain is late (1.5–3 hours later) or occurs on an empty stomach, and is relieved by eating.
Why does a doctor need to know if the patient enjoys eating?
Loss of pleasure from eating, combined with weight loss and changes in appetite, is an important element of differential diagnosis. This helps the physician determine the nature of the process and rule out severe organic pathology.
What else to study on this topic
- Methodology and technique of physical examination (abdominal palpation).
- Patient preparation and interpretation of EGD results.
- Gastric radiography: capabilities of the method and main signs of pathologies.
- Differential diagnosis of gastrointestinal bleeding.
- Mechanisms of development of dyspeptic symptoms (nausea and vomiting).
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