Linesdividingtheabdomen:L1=Transpyloric//L5=TranstubercularandTwomid-clavicularlines

•Visceralpain(midline,deep,poorlylocalized)isconductedviasymp.splanchnicnerves.•Somaticpain(lateralised,localized)arisesfromtheparietalperitoneumandabdominalwallandisconductedviaintercostalnerves.

Inflamationandmalignanciesonsetisusuallygradual

Rtupperquadranttotheback(tipofscapula)=biliarycolic

•Alteredbowelhabits=IBS,Colorectalcancer,Diverticulardisease•Breathlessness&Palpitations=non-alimentarycause•Tachycardia&Hypotension=sepsisorbleeding

Thereisasilentintervalof1-2hrsafterperforation

Itcancauseesophagealspasmandcentralchestpain,whichmaybeconfusedwithcardiacpain.

Longstandingdysphagiawithoutweightlossbutwithheartburn=benignpepticstricture.

•Bothareassociatedwithpallor,sweatingandhyperventilation.•Nausea,vomiting+abdominalpain=upperGIdisorders.•Dyspepsiacausesnauseawithoutvomiting.•Pepticulcerscausepainlessvomitingunlesscomplicatedbypyloricstenosis,whichcausesprojectilevomitingoflargevolumesofgastriccontentthatisnotbile-stained.•Obstructiondistaltothepylorus=bile-stainedvomit.•Severevomitingwithoutsignificantpain=gastricoutletorproximalsmallbowelobstruction.•Faeculentvomitingofsmallbowelcontents=distalsmallbowelorcolonicobstruction.•Vomitusinperitonitis=smallinvolumebutpersistent.•Themoredistalthelevelofintestinalobstruction,themoremarkedtheaccompanyingabdominaldistensionandcolic.•Vomitingiscommoningastroenteritis,cholecystitis,pancreatitisandhepatitis,typicallyprecededbynauseabutinraisedintracranialpressuremayoccurwithoutwarning.•Severepainmayprecipitatevomiting,asinrenalorbiliarycolicormyocardialinfarction.•Anorexianervosaandbulimia=self-inducedvomiting.•Inbulimia,weightismaintainedorincreased.Inanorexianervosaprofoundweightlossiscommon.

•BelchingmayindicateanxietybutsometimesaccompaniesGERD.•Excessiveflatusoccursparticularlyinlactasedeficiencyandintestinalmalabsorption.•Loudborborygmi,particularlyifassociatedwithcolickydiscomfort,suggestsmallbowelobstructionordysmotility.

-Obstructivejaundice+abdominalpain=gallstones.-Obstructivejaundice+abdominalpain+fever/rigors(Charcot’striad)=ascendingcholangitis.-Painlessobstructivejaundice=malignantbiliaryobstruction(cholangiocarcinomaorcanceroftheheadofthepancreas).

•Gilbert’ssyndromeisanADcondition;haemochromatosisandWilson’sdiseaseareARdisorders.•IBD=Crohn’sdiseaseorUC.•Colorectalcancerinafirst-degreerelativeincreasestheriskofcolorectalcancerandpolyps.•Pepticulcerdiseaseisfamilial,butthismaybeduetoH.pylori.•Autoimmunediseases(thyroiddisease)arecommoninrelativesofthosewithprimarybiliarycirrhosisandautoimmunehepatitis.•Afamilyhistoryofdiabetes=NAFLD.

•Smoking:increasestheriskofesophagealcancer,colorectalcancer,Crohn’sdiseaseandpepticulcer,whileptswithUCarelesslikelytosmoke.•Stress:irritablebowelsyndromeanddyspepsia.•Travel:relevantinliverdiseaseanddiarrhea.

Impairedinhepaticencephalopathy

-Striaindicateweightgain,pregnancyor,rarely,Cushing'ssyndrome.-Looseskinfoldsindicaterapidweightloss

Jaundice&Pallor

-Irondeficiency=angularcheilitisandatrophicglossitis-FolateandB12deficiency=beefy,rawtongue.-CeliacandIBD=aphthousulcers-Odorssuchasthatfromalcoholicpatientsandfetorhepaticus

Troisier'ssign=enlargementoftheleftsupraclavicularLNingastricandpancreaticcancer.

WidespreadLAP+Hepatosplenomegaly=Lymphoma.

Breast(atrophy/gynaecomastia),hairdistribution,scratchmarks,andspidernaevi

Alteredmentalstate,jaundiceandascites

Fetorhepaticus=Portosystemicshunting+/-encephalopathy

Bilateralparotidswelling=chronicalcoholabuseandbulimia.

Skincreases&Musclewasting

Gyaencomastia,lossofbodyhairandtesticularatrophy=DuetoreducedestrogenbreakdowninLiverfailure

Fingerclubbing&Tarstaining=livercirrhosis,IBDandmalabsorbtion(Celiac).

Koilonychia&Leuconychia=Hypoalbuminemia

Palmarerythemaandspidernaevi

Dupuytren'scontracture=Alcohol-relatedCLD

Dupuytren'scontracture=Alcohol-relatedCLD

Asterixis=Hepaticencephalopathy

-Shape:Flat,scaphoid,roundedorprotuburebt-Umbilicus:Flatoreverted(ascites),sunken(obese),orinverted(normal).-Thoracicrespirationincaseofperitonitis.

1-Seborrheicwarts:age-related2-Hemangiomas(Campbelldemorgan/cherryangiomas):age-related

1-Diffuseduetoascitesorintestinalobstruction2-Localizedduetoamassoranenlargedorgan

1-PortalHTN(caputmedusae)2-Venacavaobstruction(mainlyinferior)

1-Incisionalhernia2-Infraumbilicalincisionorpuncturescars(previouslaparoscopy)3-Surgicalstomas(ileostomy/colostomy)

Obviouswhenapatientcoughsorraiseshishead

Anxiety,protection

Parietalperitoneuminflammation

Generalizedperitonitis

-Tendernessinseveralareas-Board-likerigidity;itnolongermoveswithrespiration

‘Reboundtenderness’

Murphy'ssign

-Pulsatilemasspalpableintheupperabdomen=normalaorticpulsationinathinperson,agastricorpancreatictumor,oranaorticaneurysm.-Hardsubcutaneousnoduleattheumbilicus=metastaticcancer(‘SisterMaryJoseph’snodule’).

-Hepaticenlargementduetometastatictumorishardandirregular.

-Hepaticenlargementduetometastatictumorishardandirregular.-InRHFthecongestedliverisusuallysoftandtender;apulsatileliverindicatesTR.

-Thenormalliverisdullovertherightanteriorchestbetweenthe5thribandthecostalmargin.-Theliverisenlargedinearlycirrhosisbutshrunkeninadvancedcirrhosis.-Resonancebelowthe5thintercostalspacesuggestshyperinflatedlungsortheinterpositionofthetransversecolonbetweentheliverandthediaphragm(Chilaiditi’ssign).

-Abruitovertheliver=acutealcoholichepatitis,hepatocellularcancerandAVmalformation//oratransmittedheartmurmur.

Rarelypalpableandresultsfromeitherobstructionofthecysticduct(mucocoele,empyemaofthegallbladder),orapatentcysticduct(pancreaticcancer).

Formild-moderateascites

Formassiveascites

-Absenceofbowelsounds=paralyticileusorperitonitis.-Increasedsounds=intestinalobstruction.

Atheromatousoraneurysmalaorta,orsuperiormesentericarterystenosis.

Overtheliver(perihepatitis)orspleen(perisplenitis).

Anaudiblesplash(>4hrsaftereating)=delayedgastricemptying(pyloricstenosis).